The Annual Health Check

1
The Annual Health Check Presentation to the PCT
Board
Yvonne Connolly Associate Director Clinical
Governance Risk Katie Doran Governance Project
Manager 19th March 2008
2
Running order

• Definitions of Compliance
• Processes in place for this year
• Discussion of standards where concerns remain
• Summary of next steps

3
The Declaration Core Standards

• Three parts
• Standards where the board has reasonable
  assurance that there have been no significant
  lapses in meeting core standards within the
  current financial year
• Details of any standard/s for which the
  assurances received by the board make it clear
  that there have been significant lapses
• Standards where there is insufficient evidence

4
Reasonable Assurance- Definition
The trust board has received reasonable
assurance that the trust has complied with the
core standards without significant lapses
Healthcare Commission Guidance

• Have taken reasonable steps to ensure that
  independent contractors and commissioned services
  meet the standards
• Quality of information underpinning evidence
• A focus on what is working in practice

5
Significant Lapse- Definition

• Core element specific
• Severity (for patients, public, staff and/or the
  organisation) and likelihood of occurrence.

The declaration is not intended as a medium for
reporting isolated, trivial or purely technical
lapses in respect of the core standards
Healthcare Commission Guidance
6
Processes in Provider Services

• Achieved level 2 NHSLA assurance for (C1a, C9,
  C10a, C11b, C14a, C14c and C20a)
• Team tool identifies practice within services
• Leads identified for each standard
• Governance Committee responsible
• Templates completed by leads and challenged by
  relevant committee
• Outstanding actions followed up
• Recommendation to Board

7
Processes With Independent Contractors (ICs)

• Safety Alert process strengthened
• HCC standards mapped into contracts
• Self assessment questionnaire to all ICs
  including optometrists (poor response so far but
  additional staff member to follow up)
• Follow up request for evidence
• Sample visits to practices
• Follow up of actions

8
Processes in Commissioning

• Quality issues in service level agreements with
  outline of monitoring
• Commissioning managers monitor at regular
  meetings (following commissioning restructure)
• Scrutiny of cross checking data for SGH and SW
  London and St Georges to be followed up by
  commissioning managers
• Cross membership of relevant committees (prison,
  SGH Clinical Effectiveness etc.)

9
Position in Previous Years

• 2005-6 Declared insufficient assurance for
• Safety Alert Broadcast System (C1b)
• Sector Wide Decontamination Project (C4c)
• Clinical supervision (C5b)
• 2006-7 Declared non compliance with
• Decontamination (C4c)
• Infection Control (C4a)

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Standards to be Considered

• 13 in total
• Taking each in turn

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Standards to be agreed
SABS Alerts
Concerns

• WPCT was qualified for SABS alerts for its
  independent contractor groups. An action plan
  has ensured a fully operational system from
  November 2007 but not for the whole year

Strengths

• Systems for Provider Services endorsed at
  Healthcare Commission visit in June 2006

12
Standards to be agreed
Child Protection
Concerns

• The Safeguarding Lead has not been in post for
  the full year
• Provider Services training figures are lower than
  required against mandatory training requirements
• Independent contractor training has only just
  begun so numbers trained are low

Strengths

• Provider Services fully participated in the Team
  Tool Safeguarding Children and Vulnerable Adults.
  The action plan is regularly followed up
• Safeguarding Lead now in post and coordinating
  the work across the PCT

13
Standards to be agreed
Infection Control
Concerns

• PCT does not have full time Infection Control
  Lead.
• Infection control audits identified gaps but
  actions underway
• Update of infection control manual is still
  underway
• GPs audits underway - 24 to be completed by April
  2008
• Dental audits delayed- commencing end March 2008
• Staff survey results below average for
  handwashing facilities.
• St Georges continue to report high levels of
  Clostridium difficile

Strengths

• Contracted Infection Control cover in place
• Microbiological advice now available
• NHSLA Level 2 gives partial compliance
• Team Tool for infection control carried out and
  action plan in place
• Training figures improved

14
Standards to be agreed
Sector wide Decontamination
Concerns

• Sector wide group has commissioned work towards
  meeting the 'Medical Devices Directive (MDD)
  93/42 EEC' but will not be implemented until
  new financial year
• This affects all 5 PCTs in South West London.
  (This standard was not met last year).

Strengths

• Decontamination work has significantly advanced
  on last year and no incidents relating to
  decontamination have been reported

15
Standards to be agreed
Challenging Discrimination
Concerns

• Staff survey below average for training on
  equality and diversity

Strengths

• Full template for this standard signed off by
  Human Resources Governance because of extensive
  work that has been carried out in this area.

16
Standards to be agreed
Staff Personal Development
Concerns

• Staff survey - 40 staff report that they have
  had no appraisal in last 12 months slightly
  above national average.

Strengths

• Team Tool results have led to a corporate action
  plan to address the areas of concern

17
Standards to be agreed
Ensure Systems of Research Governance
Concerns

• St Georges Hospital declaring not met for this
  standard

Strengths

• Sector lead for research governance with good
  systems and processes within the PCT

18
Standards to be agreed
Staff act in accordance with confidentiality
principles
Concerns

• Staff survey results below average for training
  on how to handle confidential information

Strengths

• The PCT consistently scored significantly above
  average for the Information Governance Toolkit.
• Team Tool shows reasonable compliance in this
  area with action plan in place

19
C14c
Act on Concerns from Complaints and make changes
Concerns

• PPI concerns see C21.

Strengths

• NHSLA Level 2 full assurance
• Evidence of changes to service delivery through
  complaints management

20
Standards to be agreed
C16
Information is available and accessible for
patients
Concerns

• PPI comments a issue regarding information sent
  to patients was not seen to be dealt with
  satisfactorily and there are non-emergency
  transport issues.

Strengths

• Partial compliance from NHSLA Level 2
• Team Tool monitored this and action plan in place

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Standards to be agreed
C17
Staff act in accordance with confidentiality
principles
Concerns

• Staff survey results below average for training
  on how to handle confidential information

Strengths

• The PCT consistently scored significantly above
  average for the Information Governance Toolkit.
• Team Tool shows reasonable compliance in this
  area with action plan in place
• Positive PPI comments.

22
Standards to be agreed
Patient choice in access to services and treatment
Concerns

• Staff survey below average for equality and
  diversity training

Strengths

• Single Equality Strategy in place
• Choice in acute commissioned services and in more
  evening and weekend services
• Regular follow up of the Diversity Action Plan

23
Standards to be agreed
Care is provided in well designed and well
maintained environments
Concerns

• Dawes House PEAT audits not yet complete
  (expected end March 2008).
• service specification with Servite for cleaning
  but this does not include carrying out
  cleanliness audits.
• PPI concerns regarding premises at a GP practice

Strengths

• PEAT audits complete at QMH
• Matrons Charter actions underway
• Full infection control audit including aspects of
  cleanliness carried out at Dawes House and full
  action plan implemented
• Healthcare Commission inspection June 2007
  endorsed this standard

24
Standards to be agreed
Disease Prevention and Health Promotion
Concerns

• Concern raised by Healthcare Commission from
  cross checking data for Cardiovascular disease
  and Sexual Health

Strengths

• A full programme of health promotion and disease
  prevention in place with the PCT responding to
  above issues with significant evidence of
  compliance

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Next Steps

• Board are required to
• Confirm the status of the standards and agree
  which members will sign off final declaration
• Share this declaration with NHS London, OSC and
  PPI Forum to obtain their commentaries
• Submit to the Healthcare Commission and publish
  on PCT website
• To monitor the action plans for all standards,
  during the course of the next year.