HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
                                       TRUST BOARD ACTION TRACKING LIST
Actions arising from Board meetings (compiled 4 July 2012)
 NO      PAPER            ACTION                                                                             LEAD     TARGET      NEW       STATUS/
                                                                                                                      DATE        DATE      COMMENT
 May 2012
 01.05   Action tracker   Safeguarding training to be undertaken on Board time out                           MW       June        14 Aug    Reorganised to
                                                                                                                                            Aug due to lack
                                                                                                                                            of available time
 02.05   Inpatient        Date to be agreed for agreeing the solution of where patients were able to keep    MW       30 Sept               Not yet due
         survey           their belongings
 05.05   Business         Further discussion would be held with executive Directors to clarify the           JB       17.7.12               Verbal update to
         delivery         organisational arrangements for business delivery and business development                                        be given
 06.05   Corporate        Further information to be provided on nurse to bed ratio                           MW       14.8.12               Not yet due
 April 2012
 4.01    Corp Perf        Patient re-admission strategy to be developed                                      MW/YO     13 Nov               Not yet due
 March 2012
 3.01    Major trauma     A further update would be received by the Board                                     AP       17 July    11 Sep    Not yet due
 3.02    accreditation    A business case would be developed                                                  AP       30 Oct
 3.03                     Rehabilitation services would be discussed as part of the development of the        AP       14 Aug     13 Nov    Not yet due
                          Clinical Services Strategy
 3.08    Equality         A further report would be produced setting out the re-worded objectives and the     JA       13 Nov               Not yet due
         Duties           way that they would be measured
 January 2012
 1.01    C Difficle       The outcome of the Director of Infection Prevention and Control’s case note         YO      27 June     17.7.12   Verbal update to
         (part 2)         review should be reported to the Board.                                                                           be given
 November 2011
 11.1    Action           The dashboard for culture would be presented in January 2012                        JA         Jan      11 Sep    Revised date. To
         tracking                                                                                                                           be updated after
 11.3                     The staff survey actions to be combined with Denison. To include analysis of the    JA         Jan      11 Sep    Denison survey
                          respondents compared to the profile of the Trust, relative movement against
                          peers, outcomes & outputs

Issues identified from Board Committees, escalated to the Board and entered on the risk register
Issue                                             Date Board notified     Committee escalating the issue      Action taken
Adequacy of case notes (PbR report)               12 June                 Audit Committee                     Task and finish group established. Case notes
                                                                                                              to be filed in chronological order from 1.7.12
Adequacy of year end stock taking procedures      12 June                 Audit Committee                     Quarterly stock take to be undertaken and
                                                                                                              report to be presented to Committee
Referral to treatment times                       17 July 2012            Performance and Finance             Paper to be received in July quantifying the
                                                                                                              scale of the risks

Actions complete: to be removed from the Board tracker next month
Date:         Lead                                                                                                                Date
Trust Board
May           LT     All actions on the tracker to have an identified date                                                        On agenda 17.7.12
              JD     Paper on NHSL to be received                                                                                 On agenda 17.7.12
              YO     To consider the mortality driver diagram at the Board time out                                               On agenda 17.7.12
              MW     The Board Assurance Framework for 2011/12 would be closed down                                               Agreed 15.5.12
              JD     The Board development day would be used to review the wording of the BAF risks for 2012/13                   On agenda on 12.6.12
                                                                                                                                  but insufficient time.
                                                                                                                                  Agenda item 17.7.12
              JD     A new format for the external agency report would be introduced                                              On agenda 17.7.12
              MW     An update to be provided on the learning disability self assessment (Monitor Compliance Framework)           QuESt minutes 27.6.12
              AP     An update on the Clinical Services Strategy would be given at the Board time out                             Board development
              YO     An update would be received at the next meeting of the Board                                                 On agenda 17.7.12
              JD     The wording for SLM and PLC to be reviewed                                                                   On agenda 17.7.12
              JD     The target for PDR to be revised                                                                             On agenda 17.7.12
April         YO     To be investigated whether mortality information could be reported earlier                                   Minute 3.2, 15.5.12
              MW     Non Executive Director to become a member of the Infection Reduction Committee (Dr D Ross)                   Minute 3.2, 15.5.12
March         PM     Time on a Board development day would be diaried to consider the Trust’s 4 key strategies                    Board development
              JA     A paper on staff perceptions would be presented                                                              On agenda 17.7.12
January              The Audit Committee to consider the Quality Accounts for 2011/12 once externally audited                     Meeting held on 26.6.12
November      JD     A more detailed report on External agency visits to be received every 6 months to be timetabled so that it   Meeting 15.5.12
                     does not duplicate the annual Audit Committee review
              JB     An equality impact assessment to be undertaken on the IM&T strategy                                          Completed
              JA     Absence information to be presented by planned & unplanned absences                                          Information presented by
                                                                                                                                  short term and long term
                                                                                                                                  absence 15.5.12

Actions delegated to Committees
Date:          Lead                                                                                                            Date
Trust Board
Audit Committee
Sept           JD      A summary of all accreditation visits to be presented to the Audit Committee annually                   27.7.12
Quality, Effectiveness and Safety Committee
Sept           YO      The Society for Cardiothoracic Surgery to review patient selection (Mortality Reduction Committee)      Report received.
Quality Governance and Assurance Committee
May            JD      To continue to review progress against the NHSLA assessment in September                                On agenda 30. 5.12
               JD      To review compliance against technology appraisals                                                      On agenda 30. 5.12
               JD      To oversee the delivery of the CNST after action review plan
FT Project Board
May            JB      LTFM to be a major agenda item in June                                                                  On agenda 26.6.12
Performance and Finance Committee
May            AP      Referral to treatment times in neurology and upper GI to be reviewed                                    On agenda 29. 5.12
               JA      Clarification to be given on staff profile table and reduction in posts                                 On agenda 26.6.12
               JB/     Corporate performance report to contain key indicators to enable the Board to track impact of changes   Discussed 26.6.12.
               AP                                                                                                              Information to be
                                                                                                                               received from Business
                                                                                                                               Delivery Board and
                                                                                                                               reported to Performance
                                                                                                                               and Finance Committee
Infrastructure and Investment Committee


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