NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST

CLINICAL GOVERNANCE DEVELOPMENT PLAN 2007-2008, INCLUDING S4BH ACTION PLAN

ACTION PLANNED	LEAD RESPONSIBILITY	BY WHEN	MONITORING	OUTCOME/ OUTPUT MEASURE	UPDATE
CNST - MATERNITY	Achievement of CNST Maternity Standards at Level 2	Family Health Clinical Director & Clinical Lead	January 2008	Clinical Risk Committee	Achievement of CNST Level 2 Maternity Standards	Evidence submitted to NHSLA October 2007. Formal assessment January 2008.
NHSLA RISK MANAGEMENT STANDARDS	Achievement of new NHSLA risk management standards at Level 1	Medical Director	March 2008	Clinical and Organisational Risk Committees	Achievement of Level 1 against the new standards	Project team in place and self-assessment to be completed by 9 January 2008, including risk assessed gap analysis.
S4BH SAFETY DOMAIN – STANDARD C1, INCIDENT REPORTING AND LEARNING FROM INCIDENTS	Unification of Incident Reporting Policies and Procedures	Medical Director	November 2007	Risk Management Committee	Approved policies and procedures and targeted training in their usage	Policies approved at November 2007 Trust Board. Training to be undertaken as part of wider risk management training starting in January 2008. Underpinning procedures for Incident Reporting being developed by Incident Review Committee with target date for completion, including training, end of March 2008.
S4BH SAFETY DOMAIN – STANDARD C1, INCIDENT REPORTING AND LEARNING FROM INCIDENTS	Ensure that all Serious Untoward Incident Investigation Reports are completed within 3 months of the incident (SHA requirement)	Medical Director	October 2007	Clinical Risk Committee	Reports completed within 3 months	New SUI policy, approved November 2007, emphasises timescale but gives appropriate discretion to Inquiry Lead. Monitoring via Clinical Risk Committee
S4BH SAFETY DOMAIN – STANDARD C1, INCIDENT REPORTING AND LEARNING FROM INCIDENTS	Develop better systems to capture improvements/ changes in practice as a result of incident reporting.	Directorate Management Teams.	March 2008	Clinical Risk Committee Clinical Effectiveness Committee	Quarterly reports containing improvements made.	Clinical Leads in place with responsibility for development of local improvement plans as a result of incidents and sharing through local and Trust –level committees.
S4BH SAFETY DOMAIN – STANDARD C2, CHILD PROTECTION	Implement and monitor adherence to Trust policies and procedures, notably on CRB checks and checks for new employees and their supervision.	Director of Human Resources. Medical Director	August 2007	Safeguarding Children and Vulnerable Adults Committee.	Internal Audit sign off that all actions complete following testing of adherence to Trust policies and procedures.	CRB policy agreed and new systems in place Challenged by appointments process for new doctors – local managers aware of degree of supervision required – endorsed by Safeguarding Children and Vulnerable Adults Committee. Internal Audit reported to November 2007 Audit Committee on progress, further follow-up in May 2008.
S4BH SAFETY DOMAIN – STANDARDS C2 & C10(A), CHILD PROTECTION	Introduce e-learning package for Child Protection Training particularly concentrating on directorates who have children on adult wards.	Named Nurse and Named Doctor for Child Protection.	September 2007	Clinical Risk Committee	Training records	E- learning package now available and being rolled out. Trainer capacity restored (vacancy filled). SHA performance management review revealed no areas of concern.
S4BH SAFETY DOMAIN – STANDARD C4(A), HEALTHCARE ACQUIRED INFECTION	To reduce the number of hospital acquired infections	Medical Director Director of Estates and Facilities	March 2008	Clinical Risk Committee	Infection control performance reports show reduction in incidence in line with planned trajectory	Saving Lives and Hygiene Code Action Plans reviewed and updated October 2007 and now merged with DoH action plan. Regular weekly performance management with Clinical leads and monthly performance reporting against agreed set of KPIs. DoH review of progress December 2007 – positive feedback. December 2007 performance for MRSA bacteraemias on target.

S4BH SAFETY DOMAIN – STANDARD C4(B), ACQUISITION AND USE OF MEDICAL DEVICES	Development of Single Use Policy, including risk assessment process	Medical Director	November 2007	Clinical Risk Committee	Approved policy and procedures and targeted training in their usage	Draft policy approved by Directors’ Group – 15 November 2007.
S4BH SAFETY DOMAIN – STANDARD C4(D), MEDICINES MANAGEMENT	Improved compliance with Standards for Better Health (as reflected in the Trust Policy on Medicines Management)	Chief Pharmacist Directorate Management Teams.	February 2008	Clinical Risk Committee	Evidence to support improved compliance with Standards for Better Health Declaration and final report to Risk Management Committee on achievement of action plan.	New Policies on Medicines Management introduced from September 07. Prescribing competency framework being developed.
S4BH CLINICAL AND COST EFFECTIVENESS DOMAIN – STANDARD C5(A), TAKING ACCOUNT OF NATIONALLY AGREED GUIDANCE WHEN PLANNING AND DELIVERING TREATMENT AND CARE	Develop a National Service Framework for Older People Strategy Group that will interpret and monitor compliance with the NSF and New Ambition for Old Age.	Pathway Lead for Older People.	March 2008	Clinical Risk Committee	Strategy Group in place	Pathway Lead convening strategy group to develop service development strategy for older people based on NSF.
S4BH CLINICAL AND COST EFFECTIVENESS DOMAIN – STANDARD C5(A)	Ensure the development and delivery of actions plans for each of the NSF’s	Pathway Leads and Clinical Directors	March 2008	Clinical Effectiveness Committee	Completed action plans	Action plans in place and being monitored by Clinical Effectiveness Committee.
S4BH GOVERNANCE DOMAIN – STANDARD C7(C), SYSTEMATIC RISK ASSESSMENT AND RISK MANAGEMENT	Directorate Risk Registers to include business risks particularly in regard to the merger and integration	Medical Director Directorate General Managers	December 2007	Organisational Risk Committee.	Significant Risk Register approved by RMC	Significant Risk Register review by RMC November 2007 – risks included.
S4BH GOVERNANCE DOMAIN – STANDARD C7(E), CHALLENGING DISCRIMINATION, PROMOTING EQUALITY AND RESPECTING HUMAN RIGHTS	Organisation wide implementation of the Trust’s Race Equality Policy through enhanced training and the development and delivery of a monitoring tool	Director of Human Resources	December 2007	Organisational Risk Committee	Training records	Single, unified Equality Scheme approved by Trust Board in December 2007. Action plan in place for implementation. HCC Race Equality Review taking place 7 January 2008.
S4BH PATIENT FOCUS DOMAIN – STANDARD C13(B), SYSTEMS IN PLACE TO ENSURE APPROPRIATE CONSENT	Unification of Consent Policy Staff undertaking consent under delegation must have their competency assessed and documented.	Medical Director All Clinical Directors Medical Director	December 2007 December 2007	Clinical Risk Committee Clinical Risk Committee	Approved policies and procedures and targeted training in their usage Up to date central register	Unified Consent Policy being submitted to Trust Board in January 2008. Work continuing on populating a central register from local (departmental) databases and ensuring consistency of approach.
S4BH PATIENT FOCUS DOMAIN – STANDARD C16, PROVISION OF INFORMATION ON CARE AND TREATMENT IN SUITABLE AND ACCESSIBLE FORMATS	Access to interpreting services out of hours to be made available across the trust.	Director of Nursing	September 2007	Patient Partnership Group	No incidents reported.	In place – bookable service and 24/7 via Language Line (backup NHS Direct)
S4BH CARE ENVIRONMENT AND AMENITIES DOMAIN – STANDARD C21, WELL-DESIGNED AND WELL-MAINTAINED ENVIRONMENTS WITH CLEANLINESS LEVELS THAT MEET NATIONAL SPECIFICATION	Assessment of whether cleaning levels meet national specification through ‘Credits for Cleaning’ analysis	Director of Estates and Facilities	November 2007	Organisational Risk Committee	Match of domestic resources to national cleaning requirements	Credits for cleaning analysis will be complete in November 2007. DEF to report to Directors’ Group and Board on any resource gaps in order to inform investment decisions