PCT

Document Sample
PCT Powered By Docstoc
					             Update on Murray Learning Review Action Plan – March 2009                                                                              Agenda Item 09 05 02 i
                                                                                                                                                              Appendix 3
                                                                                                                                                                  Part 1a
PCT   Original actions identified in “Learning Review Action Plans” in 2004,        MIAA      The position for NHS Halton and St Helens as at March 2009
Ref   2005 and 2006                                                               rating of
                                                                                  St.Helen
                                                                                  s PCT in
                                                                                    2006
1     Copy MIAA report – Information Survey Template circulated
2     Action Plan – re information Survey – March 2006                                        RECORD KEEPING, RECORDS MANAGMEMENT (STORAGE & RETRIEVAL
3     Evidence of action plan re information survey being monitored:
      Group – Information Governance Steering Group (reporting to Integrated                  Rationale: Ensure the PCT has in place robust record keeping and record
      Governance Board).                                                                      management processes. This will mean that health records are improved and
4     Minutes of Joint Information Governance Steering Group to provide                       easily understood and that all PCT documents are stored in such a way that they
      evidence of action plan being monitored                                                 are secure and can be recalled when necessary.
5     Integrated Governance Board receiving Minutes of Information Governance
      Steering Group – evidencing it having monitored the action plan following               These actions were identified by the learning review team as being required to address a
      information survey                                                                      full range of issues associated with both record keeping in terms of entries within a health
6     Confirmation of appointment of Senior Records Manager – interview – Feb                 record and the storage and retrieval of health records, complaints records and other
      06                                                                                      documents that were held by the PCT and its predecessors.
7     Job Description of Senior Records Manager
8     Records Data protection and Governance Manager – Commence June 06                       Halton and St Helens PCT has a Records Management Strategy that sets out the
9     Records Management Evidence of review of policies and procedures –                      overarching framework for integrating current records management initiatives as well as
      March 06                                                                                recommending new ones. It defines a strategy for improving quality, availability and
      Which Committee and Minutes?                                                            effective use of records in the Trust and provides a strategic framework for all records
                                                                                              management activities. The strategy relates to all clinical and non-clinical operational
10    Communication and training of Records Keeping Policy / Change to clinical
                                                                                              records and is compliant with the DoH publication Records Management: NHS Code
      staff
                                                                                              2006. The Code details the length of time all documents should be stored and this is
11    Communication and training of Records Keeping Policy / Change to
                                                                                              detailed in the PCTs policy.
      independent contractors
12    Evidence of secondment of Senior Librarian – Feb 2006 – 12 months
                                                                                              The PCT has a policy on the Storage and Retrieval of Records that is compliant with
13    Evidence of „buddying‟ and mentoring arrangements with neighbouring                     the national standards on Information Governance. The policy is designed to provide
      Trusts                                                                                  comprehensive guidance and advice to all PCT staff to assist with the securing and
14    Policy for record keeping developed                                                     safekeeping of health and non health records created by the PCT. The policy is updated
15    Policy for record keeping approved – due by July 2005                                   on a regular basis and is supported by an implementation programme.
      Feb 2005 Board
16    Record Keeping Policy details length of time for storage?                               The PCT has purchased an electronic document management system,Deployer and the
17    Record Keeping Policy included within appointment letter (directly                      Assistant Director of Performance is now working to implement this within the PCT so
      employed staff)?                                                                        that staff can have ready access to all policies and procedures.
                                                                                                                                                                           th
                                                                                              The PCTs Editorial Board has developed an Intranet site that went live on 5 November
                                                                                              2007. All policies and procedures will be available on both the intranet and the Internet.

                                                                                              The PCT has a policy on the use of Safe Haven Fax Machines. The policy ensures




                                                                                                                                                                                   1
Update on Murray Learning Review Action Plan – March 2009                                                   Agenda Item 09 05 02 i
                                                                                                                      Appendix 3
                                                                                                                          Part 1a
                                                      compliance with the PCT’s Confidentiality Code of Conduct that was produced in
                                                      February 2007.

                                                      In December 2006 an Information Governance training programme commenced and to
                                                      date over 750 staff have attended the training. Information Governance covers the full
                                                      range of issues associated with record keeping, storage, retrieval, disclosing of
                                                      confidential data and information sharing with key partners.

                                                      In August 2007 a “Master Class” on Record Keeping and Record Management
                                                      commenced and these will be run every 2 months. At the end of October 2007 46 staff
                                                      had attended the Master Class.

                                                      Both predecessor organisations had in place Record Keeping policies, these have been
                                                      reviewed and consolidated and a new Record Keeping Policy has been produced. All
                                                      staff have access to training and the PCT retains records of all of those staff who attend.
                                                      Staff receive regular updates on record keeping issues via email cascades from the
                                                      Communications Team and in “The Brief” which is the PCT staff news bulletin.

                                                      The PCT has in place an Information Governance work stream that is led by the
                                                      Assistant Chief of Operations (IG) and supported by a team comprising an Information
                                                      Governance Officer and Records Management Assistant. The IG workstream meets
                                                      bi-monthly to review the full range of information governance issues including record
                                                      keeping, records management, records storage, Subject Access Rights Notifications
                                                      (SARNS), Freedom of Information requests (FOI) as well as information sharing between
                                                      staff in the PCT and external agencies. The IG workstream has a line of reporting and
                                                      accountability to the Governance Assurance Committee which reports to the Board.

                                                      Record Keeping forms part of the training that is provided at Protected Learning Time
                                                      events for independent contractors. The most recent Record Keeping policy will be
                                                      shared with independent contractors in both Halton and St Helens with a request that they
                                                      adopt the policy within their own practice areas.

                                                      PCT employment contracts stipulate a requirement for all members of staff to comply with
                                                      all policies and procedures implemented within the PCT.

                                                      In 2005 the Government began to roll the NHS Connecting for Health programme
                                                      (CfH) that will eventually allow healthcare professionals access to a patients full medical
                                                      history. PCT staff and independent contractors receive regular updates and information
                                                      leaflets on progress in respect of this initiative.

                                                      This work is led and developed by the Information Governance work stream




                                                                                                                                            2
            Update on Murray Learning Review Action Plan – March 2009                                                             Agenda Item 09 05 02 i
                                                                                                                                            Appendix 3
                                                                                                                                                Part 1a
                                                                            November 2008 update

                                                                            Record Keeping, Records Management and information governance continues to have a
                                                                            high profile in the organisation. There are a range of policies covering the respective
                                                                            components of information governance that are reviewed on a regular basis and shared
                                                                            widely with staff. The Information Governance Work Stream and its Record Management
                                                                            Sub group ensure that there is a whole systems approach to information governance and
                                                                            that any operational issues are addressed swiftly. Record keeping and information
                                                                            governance feature as part of the organisations induction programme and this is
                                                                            supported by a programme of training, including a Record Keeping Master Class
                                                                            available for all staff.

                                                                            This work is now led and developed by the Information Governance work stream
                                                                            (which reports to the Governance Assurance Committee) and the Records
                                                                            Management Group (which reports to the Information Governance Work stream

18
     Existing Staff, Declaration of concurrent employment to HR – End Dec
     2004                                                                   CONCURRENT EMPLOYMENT
19   Independent contractors to seek advice from COM
                                                                            Rationale: PCT to obtain details of concurrent employment so that all agencies
                                                                            employing that individual can be notified when a healthcare professional presents
                                                                            a risk to patient safety and also the other agency may be able to provide details on
                                                                            any issues of concern

                                                                            This was identified as a an action by the learning review so that the PCT has a full
                                                                            understanding of the activities of its employees and can alert other agencies if necessary
                                                                            when a member of staff or an independent contractor is identified as being a risk to
                                                                            patients.

                                                                            The PCTs contract of employment for staff stipulates that all staff must declare details of
                                                                            any concurrent employment. The PCT Standing Orders also require staff to declare in
                                                                            the Register of Interests details of employment were a conflict of interest may arise. The
                                                                            Register is updated regularly and presented to the Board on a 6 monthly basis.

                                                                            Staff have access to advice on when a declaration in the Register of Interests is
                                                                            necessary.

                                                                            The PCT writes out to GPs on annual basis requesting details of concurrent employment
                                                                            and the Human Resources team retains a list with these details and also has a system in




                                                                                                                                                                 3
             Update on Murray Learning Review Action Plan – March 2009                                                                   Agenda Item 09 05 02 i
                                                                                                                                                   Appendix 3
                                                                                                                                                       Part 1a
                                                                                    place for following up those who do not respond.

                                                                                    This work is led and developed by the Workforce Development team

                                                                                    November 2008 update

                                                                                    Declaration of concurrent employment is a contractual obligation for all staff and
                                                                                    independent contractors. NHS Halton and St Helens writes to all staff and independent
                                                                                    contractors on an annual basis requesting any such declaration.

                                                                                    This work is led and developed by the Workforce Development Team



20   Records Management Policy document
21   Staff survey of records – All staff have been asked to review their records    SEE RECORD KEEPING, RECORD MANAGMENTS (STORAGE & RETRIEVAL)
     management
22   Establishment of Safe Haven – All appropriate records will be archived and
     moved to Safe Haven storage facility
23   Booklet „NHS Connecting for Health‟ – Healthcare Records has been
     distributed to all NHS Clinics and GP surgeries
24   Establishment of website and intranet page to contain all newly revised
     policies – Feb/April 06


25   Issue guidance re record keeping relating to intimate examinations.
     Letters to GPs etc about recording Chaperone and READ codes.                   CHAPERONING
26   Chaperone surveying results to Clinical Governance Department
                                                                                    Rationale: To ensure that patients can request a chaperone be in attendance
     Presentation given to clinical staff – content re patient consent and record   during a visit to any healthcare appointment and are aware of their right to be able
27   keeping. Independent contractors to be contacted and advised of                to do so.
     availability of training.
                                                                                    The PCT has in place a Chaperone Policy. The policy requires healthcare professionals
28   Rerun of chaperoning survey baseline – due 2006 Outcomes?                      to offer chaperones if patients or clinical staff require them to be present. The policy is
29   Chaperone Survey Reported to?                                                  compliant with the DoH Model Chaperone Policy. The policy is updated on a regular
                                                                                    basis and is supported by an implementation programme and training for staff and for
30   Chaperone Survey Actions?                                                      independent contractors. The implementation of the policy includes notification by email
                                                                                    cascade and notices in “The Brief”.
31   Evidence of additional support to single handed practices
32   Evidence complied as part of QoF visit to highlight problems                   St Helens GPs had attended a range of sessions that provided information on




                                                                                                                                                                        4
            Update on Murray Learning Review Action Plan – March 2009                                                                 Agenda Item 09 05 02 i
                                                                                                                                                Appendix 3
                                                                                                                                                    Part 1a
33   Systematic review of record keeping relating to intimate examinations     chaperoning and this training has now featured in Protected Learning Time events for
                                                                               GPs in Halton. The PCT‟s Chaperone Policy will be sent out to GP and dental practices
                                                                               in Halton and St Helens and practitioners will be asked to adopt this policy in their locality
                                                                               and to put notices up in their waiting areas informing patients of their right to request a
                                                                               chaperone and who to ask.

                                                                               St Helens GPs use the READ codes for Chaperoning, this will be rolled out to Halton GPs
                                                                               during November and December 2007.

                                                                               The Audit Plan for 2008/09 includes an audit of the Chaperone Policy which will
                                                                               measure how well it is being implemented and followed in the PCTs own provided
                                                                               services and by independent contractors.

                                                                               In 2005 the Department of Health produced a leaflet that provided both male and female
                                                                               members of the public with information on what could be expected during an intimate
                                                                               examination. This was widely circulated and made available in all premises were patients
                                                                               could access a copy.

                                                                               This work is led by the Integrated Governance Team with support from the Clinical
                                                                               Executive Committee Chair.

                                                                               November 2008 update

                                                                               The Chaperone Policy remains in place and will be reviewed on a 3 yearly basis. In 2008
                                                                               Protected Learning Time sessions were established for Dental Practitioners and training
                                                                               was provided on Chaperoning. The Policy was sent to all GPs.

                                                                               An audit of the Chaperoning policy in GP practices was completed in 2008.


34   Ensure no more complaints records just lying around
                                                                               COMPLAINTS RECORDING
35   All complaints checked to ensure action has been taken – completed July
     05 – CAMS database.                                                       Rationale: The PCT should ensure that all complaints are recorded appropriately
                                                                               and that historical records can be accessed.
36   Clinical Governance to produce improvement action plan
                                                                               This action was addressed fully by St Helens PCT and Halton and St Helens PCT
                                                                               continues to have in place robust procedures for recording, reviewing and archiving
                                                                               complaints. To ensure that the PCT has all historical complaints data held in one
                                                                               electronic database the historical complaints from Halton PCT have been retrieved from
                                                                               the archive and the Customer Care Unit is in the process of entering the detail into




                                                                                                                                                                       5
            Update on Murray Learning Review Action Plan – March 2009                                                            Agenda Item 09 05 02 i
                                                                                                                                           Appendix 3
                                                                                                                                               Part 1a
                                                                             DATIX, the PCT‟s Integrated Risk Management System.


                                                                             This work is led by the Complaints Manager, the Customer Care Unit and the
                                                                             Integrated Governance Team



                                                                             November 2008 update

                                                                             All historical complaints from the predecessor organisations have been inputted into the
                                                                             Datix Integrated Risk Management System. This work was completed in March 2008. All
                                                                             informal and informal complaints, concerns or comments are recorded in Datix.

                                                                             The Executive Nurse/Director of Clinical Quality and Standards now has executive lead
                                                                             for overseeing the management and investigation of complaints.

                                                                             Details of complaints and the associated trends are reported to Risk Management
                                                                             Committee and via a bespoke report to the Governance Assurance Committee.

                                                                             The Comments, Concerns and Complaints Policy was revised and approved by the Board
                                                                             in September 2008.

37

     Remedial action plans by Clinical Governance following QoF visits       RECORD KEEPING IN GP PRACTICES
     - Feb 2005, 05/06
38   General Record keeping issues identified by QoF                         Rationale: Concerns about record keeping being identified in primary care and
                                                                             remedied with support from the PCT
39   QoF reviewer outcomes / concerns – referred to Integrated Governance
     Department. Defined programme to evidence monitoring of record          This needs to be considered in conjunction with the information provided in the section on
     keeping?                                                                Record Keeping, Records management (Storage and Retrieval)

40   Evidence of Audit by practice of record keeping against modernisation   St Helens PCT had in place a process whereby issues in respect of record keeping that
     Agencies Essence of Care Standard                                       were identified through the Quality Outcomes Framework (QOF) GP assessments could




                                                                                                                                                                6
            Update on Murray Learning Review Action Plan – March 2009                                                                 Agenda Item 09 05 02 i
                                                                                                                                                Appendix 3
                                                                                                                                                    Part 1a
41   Progress on issues to be included in Board 1/4ly report on Hard             be fed back into the PCT and resolved appropriately.
     Governance
42   Monitoring measures, Evidence of intervention by PCT                        The PCT continues to monitor record keeping in primary care through the QOF process.
     Defined links to risk management/Board Update to Board                      Problems are highlighted in the “QOF visit reports” which also details the remedial action
                                                                                 plans in place. Primary Care Development Managers have responsibility for ensuring that
                                                                                 practices adhere to their action plans.

                                                                                 Any significant issues are reported to the Clinical Governance Team on a reporting
                                                                                 proforma that has been produced by the PCT. The Clinical Governance Team has the
                                                                                 responsibility for following these issues up. The Clinical Governance Team has a direct
                                                                                 line of reporting and accountability to the Integrated Governance Committee which
                                                                                 reports to the Board.

                                                                                 This work is led and developed by the Primary Care Contracting team with support
                                                                                 from the Chair of the Clinical Executive Committee.

                                                                                 November 2008 update
                                                                                 The Clinical and Quality Standards Workstream has a direct line of reporting to the
                                                                                 Governance Assurance Committee. The work of the QCS will be subject to an
                                                                                 internal validation inspection in 2009.
43   Concurrent employment
     Copy declaration of concurrent employment – June 2005 – 06                  SEE CONCURRENT EMPLOYMENT
     New staff/Existing staff
44   Definition of contractor staff?                                             The PCT has in place a policy on recruitment and selection that is compliant with national
                                                                                 guidance. The PCT continues to follow its recruitment and selection policy and adheres
45   Copy of proforma declarations re Concurrent Employment returned             to national guidance in respect of pre-employment checks.

46   Revise recruitment and selection protocol – May 06




47   Using media, publications events… educate the public of services provided
     by PCT and robustness of systems                                            COMMUNICATION
48   Quarterly reports to the Board on progress re Education Public of           Rationale: The PCT should have robust internal and external communications so
     robustness of systems – March 2005                                          that staff are regularly informed of the activities of the PCT and the public are
49   Updated communication plan to the Board – Jan 2005                          consulted with and engaged in the work of the PCT.




                                                                                                                                                                     7
            Update on Murray Learning Review Action Plan – March 2009                                                                  Agenda Item 09 05 02 i
                                                                                                                                                 Appendix 3
                                                                                                                                                     Part 1a
                                                                                  The PCT has a Communications Strategy that has been agreed by the Board and
                                                                                  circulated throughout the PCT. The PCT‟s Assistant Director – Communications has
                                                                                  managerial responsibility for the dedicated Customer Care Unit comprising Complaints
                                                                                  Manager, Complaints Assistant, Patient and Public Involvement Manager as well as
                                                                                  Patient Advice and Liaison Services (PALS) staff that offer the public a range of
                                                                                  information and sign posting advice about NHS services.

                                                                                  The services provided within the Customer Care Unit are widely publicised and the unit
                                                                                  receives a significant amount of calls on a daily basis. The CCU are able to share the
                                                                                  experience of patients, users and carers both positive and negative, with the governance
                                                                                  team through regular reporting to a number of sub committees.

                                                                                  The PCT has an internet and intranet so that the public, local stakeholders and staff can
                                                                                  easily access information about the PCT.

                                                                                  The PCT has a Patient and Public Involvement Strategy and action plan. The strategic
                                                                                  sets out the PCT‟s commitment to real and meaningful engagement with its community,
                                                                                  staff and partners.

                                                                                  This work is led by the Assistant Director Corporate Services - Communications
                                                                                  with support from the Customer Care Unit.

                                                                                  November 2008 update

                                                                                  In 2007, the Communications and Involvement Strategy was developed. The strategy
                                                                                  includes views from staff, partners, service users and carers. All PCT communication and
                                                                                  involvement work now uses the principles outlined in this strategy. To support the
                                                                                  strategy, the PCT developed a robust Patient and Public Involvement Action Plan that
                                                                                  is led by the PCT Patient and Public Involvement Team to ensure that the PCT
                                                                                  continuously engages patients and the public in PCT business

50   Update of Chaperone policy – Dec 04
     Launched? (issued to staff April 04 by Risk Manager)                         SEE CHAPERONING
51   Chaperone Policy – April 2005
52   Chaperone Policy – Subject to review – Dec 2005
53   Revised Chaperone policy reviewed and ratified – January 2006
54   Chaperone Policy – Cascade to staff – April 2005?
55   Evidence Chaperone Policy rolled out to clinical staff
56   Evidence rolled out to independent contractors. Protected learning event –
     July 2006 – workshop session




                                                                                                                                                                      8
              Update on Murray Learning Review Action Plan – March 2009                                                             Agenda Item 09 05 02 i
                                                                                                                                              Appendix 3
                                                                                                                                                  Part 1a
57     Requirement to offer chaperone in essential contract monitoring –
       posters/clinical audit report 2005.
58     Requirement to offer Chaperone in essential contract monitoring –
       posters/clinical audit report Autumn 2006.
59     Evidence of monitoring of clinicians…challenge in terms of
       performance….by Poor Performance Assessment Group
60     Training programme for chaperoning policy
61 &   Training programme re Chaperone Policy delivered to Clinical staff
62
63     Training programme delivered to Professionals re Chaperone Policy
64     Training programme re Chaperone Policy delivered to practice staff
65     Database of those attending chaperone training sessions
66     Summary report from learning and development department re Chaperone
       policy to Head of Governance
67     Evidence/output of audit of chaperone policy in use
68     Audit programme re implementation of Chaperone Policy applied by
       Integrated Governance Department –Autumn 06
69     Copy of clinical Audit Report re implementation of Policy
70     Minutes of Poor Performance Assessment Group having monitored
       implementation of Chaperone policy / audit outcomes                       ADDRESSING CONCERNS ABOUT PERFORMANCE

71     Comprehensive monitoring of contracts with independent contractors –      Rationale: The PCT should have in place a mechanism for reviewing the
       Chief Performance Analyst/Integrated Governance Committee/PEC.            performance of clinical staff and independent contractors when a risk to patient
       Minutes of the Serious Incident Team having monitored implementation of   safety has been identified.
72     Chaperone policy / audit outcomes. Referral to PPAG?
73     Referral / minutes to Performers List Committee                           The Performance Assessment Group (PAG) was established as formal sub committee
                                                                                 of the Board and regularly deals with a range of issues associated with performance
                                                                                 issues relating to staff and independent contractors.

                                                                                 The Board receives regular updates on the work of this group during Part 2 of Board
                                                                                 meetings. There are clearly defined links between the Governance Team and the
                                                                                 Complaints Team so that issues that may come to light as part of these processes are
                                                                                 reported promptly to the PAG.

                                                                                 The work is led by the Director of Workforce Development and Provider Services
                                                                                 and the Chair of the Clinical Executive Committee

                                                                                 November 2008 update




                                                                                                                                                                  9
            Update on Murray Learning Review Action Plan – March 2009                                                                  Agenda Item 09 05 02 i
                                                                                                                                                 Appendix 3
                                                                                                                                                     Part 1a
                                                                                 The Performance Assessment Group continues to operate and reports, when necessary
                                                                                 to the Board. There are a number of ways in which performance issues can now be
                                                                                 picked up and reported including complaints, concerns, whistle blowing and details of
                                                                                 incidents.


74   Revised whistleblowing policy – March 2005                                  WHISTLEBLOWING
75   Whistleblowing policy to be included in Team Brief, cards – handbook
76   Whistleblowing policy part of induction training                            Rationale: The PCT should have in place systems and process so that staff can
77   Whistleblowing policy part of mandatory training                            report any issues of concern in a confidential way. These processes need to be
78   Attendance log of training regarding Whistleblowing policy – Sept 2005      understood and easily accessible.
79   Copy programme of awareness raising sessions re Whistleblowing policy.
80   Awareness raising re Whistleblowing etc. Evidence of attendance by staff    The PCT has in place a Whistleblowing Policy that has been developed in accordance
     group – to include staff and contractors                                    with the Public Interest Disclosure Act 1998. This is currently being circulated and will be
81   Evidence of improved response fro contractor re Whistleblowing policy       sent out to GPs and Dentists in Halton and Helens for them to adopt in their practices.
     awareness – PEC March 2006
                                                                                 The policy includes specific guidance on the reporting of incidents involving sexualised
                                                                                 behaviour.

                                                                                 Since 2004 the registration requirements for healthcare professionals has altered and
                                                                                 they now have a positive rather than a discretionary duty to make disclosures in the
                                                                                 interest of patient safety.

                                                                                 The PCT‟s Whistle blowing Policy will be sent out to GP and dental practices in Halton
                                                                                 and St Helens and practitioners will be asked to adopt this policy in their locality.

                                                                                 This work is now led by the Workforce Development team with support from
                                                                                 Integrated Governance

                                                                                 November 2008 update

                                                                                 The Whistle blowing policy was published in December 2007 and was made widely
                                                                                 available to all staff with a copy being sent to all independent contractors. The policy has
                                                                                 been used on a number of occasions to report concerns that have subsequently been
                                                                                 investigated. A copy of the policy is given out at induction and staff are asked to sign a
                                                                                 receipt. Credit card sized information cards on how to report concerns are soon to be
                                                                                 made available to staff and independent contractors.

82   Letter reinforcing recruitment and selection policy – CE to Directors and
     SMs




                                                                                                                                                                     10
              Update on Murray Learning Review Action Plan – March 2009                                                                     Agenda Item 09 05 02 i
                                                                                                                                                      Appendix 3
                                                                                                                                                          Part 1a
83     Procedures for appointment of locum                                            The procedures for the appointment of locums are managed by COM (Central Operations
84     Formal Service specification re COM                                            Mersey) and practitioners are required to undergo rigorous pre employment checks
85     Instances of PCT active link with COM for update re contractors / locums       before joining a Performers List.
86     Evidence of verification and check re contractors / locums
                                                                                      Work is ongoing to strengthen the service specification with COM so that the PCT can
                                                                                      continue to be assured that all GPs, including locums continue to be subject to rigorous
                                                                                      checks.

                                                                                      November 2008 update (November 07 rating was amber)

                                                                                      The Workforce Development team have now developed a protocol that requires providers
                                                                                      to provide evidence that the appropriate checks are taking place.

87     Accident and Incident reporting & Management Policy amended – May
       2005                                                                           ACCIDENT AND INCIDENT REPORTING

88     Revised serious clinical incidents policy – Jan 2006                           Rationale: The PCT should have in place a systems for reporting incidents and
8990   Replies evidencing receipt of revised policy – March 2006                      accidents to ensure that any incidents that pose a risk to patient safety can be
                                                                                      recorded, actioned and services improved as a result.
91     Documenting range of staff groups responding
                                                                                      The PCT has in place an Accident and Incident Reporting and Management Policy.
92     Programme of training to be delivered to staff re accident and incident        The policy provides comprehensive guidance to PCT staff and providers for the reporting
       reporting and management policy                                                and management of all incidents whether clinical or non clinical including near misses.
                                                                                      The policy also details the reporting of incidents of sexualised behaviour.
93     Serious clinical incidents – training for helpline staff 2004 – Delivered by
       Healthwise                                                                     The policy incorporates the report of Serious Untoward Incidents and also incorporates
94     Refresher course delivered in house by complaints manager – 2005               StEIS (Strategic Executive Information System) reporting procedures.
95     Accident and Incident reporting and management policy – Jan 2005 Update
       for helpline staff                                                             The Policy is supported by guidance for staff on how to undertake a Root Cause
96     Extract minutes of poor performers group demonstrating links re Accident &     Analysis of an event so that all the root causes are identified and remedial action take to
       Incident Reporting & Management policy – Dec 04 – Sept 06                      address them.
       Evidence active monitoring. Extract minutes of Poor Performance
97     Assessment Group/Performance list committee – TOR – May 2006                   The policy is updated on a regular basis and is supported by an implementation
98     - Extract minutes – to evidence defined reporting links between PPAG /         programme including training. The policy has been assessed by the NHS Litigation
       Clinical Gov/ Serious Incidents Team into Integrated Governance Board? -       Authority as part of its assessment cycle and is fully compliant with their standards as well
       Extract minutes –                                                              as the Healthcare Commissions Standards for Better Health.

99     Copy of revised Accident & Incident Reporting & Management policy – To         The most recent Accident and Incident Reporting and Management Policy will be shared
       Health and Safety                                                              with independent contractors in both Halton and St Helens with a request that they adopt
                                                                                      the policy within their own practice areas.




                                                                                                                                                                          11
             Update on Murray Learning Review Action Plan – March 2009                                                                  Agenda Item 09 05 02 i
                                                                                                                                                  Appendix 3
                                                                                                                                                      Part 1a
100   Evidence of significant events analysis and audit sessions (SEA sessions)
101   Awareness sessions re Accident & Incident Reporting & management            Significant Event Analysis is a key indicator for the QOF and practices are required to
      policy – lunch and learn – Dr J Holding 2005 – Haydock Park Racecourse      undertake a minimum of 3 SEAs a year. Significant Events processes follow the same
                                                                                  methodology as those applied in Root Cause Analysis.

                                                                                  All incidents are recorded in DATIX, the PCT‟s Integrated Risk Management System
                                                                                  alongside, complaints and PALS enquiries. The Claims Module will soon be included.

                                                                                  This work is led and developed by the Integrated Governance Team and associated
                                                                                  work streams.

                                                                                  November 2008 update

                                                                                  The Accident and Incident Reporting Management Policy is currently being reviewed to
                                                                                  ensure that it remains dynamic and compliant with the NHS Litigation Authority
                                                                                  requirements. In the first quarter of 09/10 a simplified reporting form is being introduced
                                                                                  which is quicker and easier to complete and will encourage greater reporting of all
                                                                                  incidents. To support the roll out of this form a training and communication strategy will be
                                                                                  developed to ensure all staff are aware of the reasons for reporting and their role and
                                                                                  responsibility for reporting

                                                                                  Incident reporting has a high profile in the organisation and a number of workstreams
                                                                                  review incidents by incident type. The Risk Management Committee continues to have
                                                                                  overall oversight of all incidents; but health and safety incidents are overseen by the
                                                                                  Health and Safety Advisory Group; the Records Management group oversees Records
                                                                                  management related Incidents; confidentiality breaches and data protection incidents are
                                                                                  monitored by the Information Goverance Workstream and the Quality and Clinical
                                                                                  Standards Workstream reviews clinical incidents. There is now also a “Lessons Learned”
                                                                                  bulletin that is sent out bi-monthly that provides details of incidents or complaints and
                                                                                  describes the way in which improvements have been made as a result.

                                                                                  The Claims module has now been included to Datix




102   Single handed GP support group having met – led by Dr J Goldstone
                                                                                  SUPPORTING AND INCLUDING GPs

                                                                                  Rationale: The PCT should have in place a system for ensuring that single handed
                                                                                  practitioners are not working in isolation from their colleagues. GPs should be




                                                                                                                                                                       12
             Update on Murray Learning Review Action Plan – March 2009                                                               Agenda Item 09 05 02 i
                                                                                                                                               Appendix 3
                                                                                                                                                   Part 1a
                                                                                 able to access peer support and be able to discuss issues of concern in a group
                                                                                 setting. The PCT should have in place a process for ensuring that single handed
                                                                                 practitioners are included in all PCT related activities.

                                                                                 St Helens PCT did establish a mentoring and support group for single handed GPs and
                                                                                 this was well attended. The group has met less frequently over the past 12 months due
                                                                                 to the development of Practice Based Commissioning that has resulted in GPs within the
                                                                                 Consortia working more closely together.

                                                                                 The Clinical Executive Committee (CEC) Chair leads on clinical engagement for the PCT.
                                                                                 The CEC agreed a process for engagement and a Clinical Leads Group has now been
                                                                                 established.

                                                                                 November 2008 update

                                                                                 This was a bespoke action that arose from the Learning Review. Over the past 12
                                                                                 months the development of Practice Based Commissioning and the Clinical Leads Group
                                                                                 has ensured that GPs work collaboratively and that single handed practitioners are
                                                                                 included in activities and work programmes.

103   Communication policy to be reviewed – Jan 2005
104   Evidence – Communications strategy revised and ratified reviewed by        SEE COMMUNICATION
      Management Team – minutes Sept 2005?
105   Evidence of Communications strategy in team brief / to staff – June 2006
106   Copy of revised Jan 2005 Communication strategy
107   Evidence of communication strategy approval. April 2005 Board minutes
108   Copy of Communications Plan in respect of serious incidents

109   Copy of Consent Policy – April 2005 – Approved by Board                    CONSENT
110   Copy revised Consent policy – Sept 2006
111   Evidence of monitoring application of consent policy                       Rationale: The PCT should have in place robust procedures for obtaining valid
112   Copy of Information Governance Programme                                   consent from patients before commencing treatment.
113   Copy of Information Governance Programme
                                                                                 The PCT has a policy on Consent to Treatment. The policy is designed to provide
                                                                                 comprehensive guidance to PCT staff and providers to ensure that the correct level of
                                                                                 consent is obtained by examination or treatment is undertaken.

                                                                                 The Consent policy is supported by a training programme that has been attended by
                                                                                 many staff. It is a dynamic document that is revised regularly to take into account
                                                                                 changes to legislation such as the Mental Capacity Act and Mental Health Act but also to




                                                                                                                                                                  13
             Update on Murray Learning Review Action Plan – March 2009                                                                Agenda Item 09 05 02 i
                                                                                                                                                Appendix 3
                                                                                                                                                    Part 1a
                                                                               reflect changes arising as a result of evolving case law.

                                                                               The Consent to Treatment Policy has been developed in accordance with the Department
                                                                               of Health Model Consent Policy and has been assessed as compliant with the NHS
                                                                               Litigation Authority Risk Management Standards and the Healthcare Commission‟s
                                                                               Standards for Better Health.

                                                                               The most recent Consent policy will be shared with independent contractors in both
                                                                               Halton and St Helens with a request that they adopt the policy within their own practice
                                                                               areas.

                                                                               The Audit Plan for 2008/09 includes an audit on the use, application and implementation
                                                                               of the consent policy.

                                                                               This work is now led by the Integrated Governance Team and associated work
                                                                               streams.

                                                                               November 2008 update

                                                                               The Consent Policy remains in place and will be reviewed in December 2008. Consent
                                                                               training is available to all staff. An audit of the Consent Policy was detailed in the Audit
                                                                               Plan for 08/09 and the audit is currently being designed.


114   Draft Information sharing policy to RMG 3/3/06 (David Hamm Consultant)
115   Governance development session with Board, PEC and Management            INTEGRATED GOVERNANCE
      Team members – Feb 2005
116   Paper recommending an Integrated governance System for PCT -             Rationale: The PCT should have in place a system of Integrated Governance so
      Approved by Board – Oct 2005                                             that all risk areas can be brought together in a cohesive framework. This will
117   Progress on implementation of Integrated Governance system.              ensure that emerging themes are quickly identified an addressed.
118   Devising pathway – clinical to integrated governance/development of
      Assurance Framework                                                      The Board received a paper in November 2006 that described the system of integrated
      Board approval – Oct 2005 (Paper)                                        governance. The PCT established an Integrated Governance Committee as a formal sub
      Exec Team event – 15/11/05                                               committee of the Board. This committee oversees the work of a range of work streams
      MIAA session – the Mansion House – 21/10/05
119   Evidence of revised arrangements communicated to all staff               Work on the development of integrated governance has continued and the Governance
      Integrated governance structure via a team brief?                        Team have recently produced a strategy for integrated governance that will strengthen
120   Governance structure in induction programme                              this further.
121   Board adoption of revised Governance structure Oct 2005 –
      Evidence of application.                                                 This work is now lead by the Integrated Governance Team




                                                                                                                                                                     14
             Update on Murray Learning Review Action Plan – March 2009                                                                  Agenda Item 09 05 02 i
                                                                                                                                                  Appendix 3
                                                                                                                                                      Part 1a
                                                                                   November 2008

                                                                                   In March 2008 the Board established a Governance Assurance Committee (GAC) that is
                                                                                   responsible for overseeing the work of the various sub groups and work streams within
                                                                                   the PCT. The GAC now has a 12 month work programme in place to receive reports
                                                                                   from the respective sub groups and work streams. Built into this is a validation plan that
                                                                                   will test out the processes used to provide assurance. Were gaps are identified
                                                                                   awareness raising and training will be made available so that the GAC can be assured
                                                                                   that the work streams are functioning optimally.

                                                                                   The work of the GAC has recently been reviewed by Mersey Internal Audit Agency.

122   Copy of Steis escalation policy/risk management group minutes – June
      2006.                                                                        SEE SECTION ON ACCIDENT AND INCIDENT REPORTING

123   „Soft Knowledge‟ to be recorded on CAMHs database
124   Written procedure for PCT managers – Oct 2006.                               COMMENTS, CONCERNS AND COMPLAINTS
125   Copy of Comments, Concerns and Complaints policy – Feb 2005
126   Copy Integrated Governance Framework – Nov 2005                              Rationale: The PCT should have in place robust systems and process for
127   Copy Proposal to Board re improved documentation real concerns of            receiving, handling and recording complaints. The PCT should also have in place a
      complaints                                                                   system and process for recording anecdotal information and informal concerns
128   Hard Governance – Systematic review learning from complaints etc.            from the public.
      Minutes, Action Plan, Reporting / referral into wider Governance forum/
      pathway to Board?                                                            The PCT has in place a Comments, Concerns and Complaints Policy. This is updated
129   Correspondence – Hill Dickinson re definition of knowledge and appropriate   on a regular basis and is supported by an implementation programme and training.
      management and recording – Sept 06                                           Training is offered to all staff including independent contractors in St Helens and Halton.
130   Learning from complaints – Copy qualitative Board report with effect from
      June 2006                                                                    The Comments, Concerns and Complaints Policy provides information to staff how to
131   Copy of PCT guidance management of knowledge/complaints to Board –           record information obtained through informal mechanisms and the process that needs to
      cross reference to complaints and whistle blowing policies                   be followed for receiving and recording “soft knowledge”.

                                                                                   Information relating to complaints is reported to the Risk Management Committee, the
                                                                                   Integrated Governance Committee and to the Board as part of the Performance Report.

                                                                                   The PCT‟s Comments, Concerns and Complaints Policy will be sent out to GP and dental
                                                                                   practices in Halton and St Helens and practitioners will be asked to adopt this policy in
                                                                                   their locality

                                                                                   This work is led by the Customer Care Unit and the Integrated Governance Team.




                                                                                                                                                                      15
             Update on Murray Learning Review Action Plan – March 2009                                                                    Agenda Item 09 05 02 i
                                                                                                                                                    Appendix 3
                                                                                                                                                        Part 1a
                                                                                      November 2008 update

                                                                                      All historical complaints from the predecessor organisations have been inputted into the
                                                                                      Datix Integrated Risk Management System. This work was completed in March 2008. All
                                                                                      informal and informal complaints, concerns or comments are recorded in Datix.

                                                                                      The Executive Nurse/Director of Clinical Quality and Standards now has executive lead
                                                                                      for overseeing the management and investigation of complaints.

                                                                                      Details of complaints and the associated trends are reported to Risk Management
                                                                                      Committee and via a bespoke report to the Governance Assurance Committee.

                                                                                      The Comments, Concerns and Complaints Policy was revised and approved by the Board
                                                                                      in September 2008 and has been sent to all GPs for use in their practices.

132   Copy written reminder sent August 06 to professional responsibility to notify
      PCT of performance concerns                                                     SEE SECTION ON WHISTLEBLOWING

133   Copy of contract of employment for health professionals – relevant clauses
      in relation to professional responsibility and code of conduct.

134   Evidence of distribution of national leaflet “What to do if you have concerns
      over a colleagues performance”
      - refer protection learning event – July 06
      Copy of leaflet, Distribution, Agenda for event
135   Training and briefing sessions to be held to reinforce message re
      professional responsibility and code of conduct
136   Confirmation of protected training and education in support of GPs to
      2005/06                                                                         SEE SECTION ON SUPPORTING AND INCLUDING GPS
137   GP support and mentoring group for salaried GP‟s and single-handed
      practices.
138   Widen current mentoring scheme for GPs to include isolated clinicians
139   Copy of the support programme issued early 2006
140   Practices provide information on Significant events within the QoF reports      Practices are required to undertake a minimum of 3 Significant Event Analysis a year.
                                                                                      This is part of the QOF assessment process.
141   Revised procedure for inclusion on professional list – Draft March 2006 –
      Performers List Committee?                                                      MANGEMENT OF THE PERFORMERS LIST FOR GPS
142   Performers list procedures formally adopted
      Which forum?                                                                    Rationale: The PCT should have in place a process for assessing applications




                                                                                                                                                                        16
              Update on Murray Learning Review Action Plan – March 2009                                                                      Agenda Item 09 05 02 i
                                                                                                                                                       Appendix 3
                                                                                                                                                           Part 1a
143   TOR/Minutes of performers list committee (Nov 2005?)                             from GPs wishing to join the Performers List
144   HR written to everyone on list to check their details re management of
      professional list                                                                The PCT has a Performers List Committee that meets regularly to review applications
                                                                                       from GPs to join the performers list. The Committee is responsible for interpreting and
145   Evidence of validation of detail for GPs on professional list?                   enforcing the NHS (Performers Lists) Regulations 2004 in relation to: admitting doctors to
146   Evidence of validation of detail for all GPs, dentists, opticians – SLA/formal   the PCT medical performers list, refusing to admit doctors, granting conditional inclusion,
      links contractor services/COM                                                    consider removals from the performers list, consider suspensions and to review decisions
                                                                                       if requested to do so.

                                                                                       The work is led by the Workforce Development team and the Primary Care Team

                                                                                       November 2008 update

                                                                                       The Performers Lists for GPs and Dentists are managed by the Workforce Development
                                                                                       Team. Any concerns are automatically refereed to PPAG.
147   Due Oct 2006 – Copy of the updated call and recall letter                        This action was completed by St Helens PCT and related to patients being recalled for
                                                                                       cervical screening due to some concerns about the test results not to the way in which the
                                                                                       tests had been undertaken.
148   Due Nov 2006 – Intimate examination leaflet                                      The Department of Health produced a leaflet that was circulated nationally. A copy of this
                                                                                       leaflet was made available in all PCT premises.
149   Evidence of education programme for anyone that may consent to an
      intimate examination                                                             This work is being developed by the Governance Team with support from public health




150   Copy of PALs leaflet posters re how to complain in general circulation.
151   Evidence/copy „Health Matters‟ column                                            SEE COMMENTS CONCERNS AND COMPLAINTS

152   PALs communication plan developed                                                This action related to an article that was published in the St Helens local paper “The Star”.
                                                                                       This article was published

                                                                                       SEE COMMUNICATION

153
      Confirmation that training has been delivered – due March 2005 Director of       This action was not as a direct result of the incident but was training that was taking place
      PH(Cervical smear training)                                                      at the time when the learning review action plan was being updated. This training was
                                                                                       “Liquid Based Cytology” training which when implemented significantly reduced the risk of
                                                                                       patients being recalled for duplicate tests.

154   Programme of reducing complaints, promoting compliments workshops for




                                                                                                                                                                            17
             Update on Murray Learning Review Action Plan – March 2009                                                                      Agenda Item 09 05 02 i
                                                                                                                                                      Appendix 3
                                                                                                                                                          Part 1a
      staff. Copy of agenda Copy of attendees listing                                     SEE COMMENTS CONCERNS AND COMPLAINTS
155   Continue with complaints training and awareness raising sessions to
      clinical teams regarding the PCT complaints process
156   Copy performance reports re complaints, PALs, H & S to Board before and
      after enhancement
157   Robust process for analysis of significant events/complaints
      Evidence of adoption and dissemination
      There were 10 further action points that MIAA considered as part of their review. Those actions related specifically to potential action required by the PCT
      following the publication of the External Review Team.




                                                                                                                                                                     18