Standards for Better Health update for Overview

1
Standards for Better Health update for
Overview Scrutiny Committee

• Jacqui Evans
• Clinical Governance Manager
• 22 February 2006

2
HCC standards for better healthinterim (draft)
declaration
3
Draft declaration

• Thank you for your comments
• Also received favourable comments from the PPI
  Forum and the SHA
• Action planning based upon comments in the
  declaration
• We have not been chosen for an inspection by the
  HCC

4
Draft declaration not met

• Decontamination (C4c)
• Units have centralised during 4/5 February
• Further building of office space
• Fully operational before end of March 2006
• External validation booked for April 2006

Should be fully compliant by 31 March 2006
5
Draft declaration insufficient compliance

• Patient safety notices (C1b)
• Child protection (C2)
• Infection control (C4a)
• Medical devices (C4b)
• NICE compliance (C5a)
• Records management (C9)
• Dignity and respect (C13a)

• Consent (C13b)
• Confidentiality (C13c)
• Patient information (C16)
• Environment/HS (C20a)
• Privacy and confidentiality (C20b)
• Cleanliness (C21)

6
Interim action plan

• Leads for each item of insufficient / non
  compliance
• Action over last few months to implement action
  plan
• Progress reported to Trust Board Assurance
  Committee
• Progress reported to SHA
• Good progress on all items

7
Specific issues

• Cleanliness (C21) insufficient assurance
• Infection control (C4a) insufficient compliance
• Discharge arrangements (C6)

8
Specific issues - cleanliness

• No specific external validation
• New contract in 2005
• Scheduled technical audits by contractors
• Scheduled managerial audits by dedicated
  monitoring officers
• Comparison of results discussed at penalty group
  meeting
• Complaints decreased to 2-3 per month
• Pre-PEAT assessment (30/1 3/2) led by nurses
  and inc patient representative
• PEAT (environment rather than cleanliness)

9
Specific issues infection control

• Trust Infection Control Committee with DIPC
• Reporting to the Board (outcomes actions)
• IC annual programme (inc. Winning Ways)
• Range of policies approved by DIPC
• Care bundles (Saving Lives, 2005)
• Audits handwashing, environmental, commodes
• Range of education opportunities induction,
  link programme, doctors
• Serious outbreaks - C. Difficile (Jan 06)
• Surveillance (weekly) on C. Diff, MRSA, VRE
• MRSA (national target) hand hygiene IV lines

10
Specific issues discharge arrangements

• Range of multi-agency meetings
• Discharge facilitators group
• Quadrant strategy meetings
• Countywide delayed transfer meetings
• Discharge Policy (Feb 05) multi-agency
• Expanded team of discharge co-ordinators
• Current focus on planning discharge dates
• Programme of audits
• Integrated care pathways -
• Single assessment process (eSAP) rollout continues

11
Summary

• Good progress in all areas of insufficient or non
  compliance
• End of year position improved
• Greater understanding of the Standards by the
  organisation