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					Royal National Orthopaedic Hospital NHS Trust
Healthcare Commission Annual Health Check
Action Plan to target “Good” rating 2007/8 for both quality & use of resources

Assessment Area                                         Action required                     Lead Director       Timescale
Quality - Core Standard C13b             To provide a comprehensive consent framework   Acting Director of    January 2008
Healthcare organisations have systems including policies, training and patient          Nursing/Joint Medical
in place to ensure that:                 information                                    Director
appropriate consent is obtained when
required, for all contacts with patients
and for the use of any confidential
patient information (not met)

Quality - Core Standard C16              To improve patient/carer information, in       Acting Director of    January 2008
Healthcare organisations make            particular by ensuring patients/carers         Nursing/Joint Medical
information available to patients and    understand their rights to ask questions       Director
the public on their services, provide
patients with suitable and accessible
information on the care and treatment
they receive and, where appropriate,
inform patients of what to expect during
treatment, care and after care (not met)

Quality - Core Standard C20a              The action plan to meet compliance with this Director of Estates   Ongoing
Healthcare services are provided in       standard is the redevelopment of the Trust.  and Facilities
environments which promote effective
care and optimise health outcomes by
being:
a safe and secure environment which
protects patients, staff, visitors and
their property, and the physical assets
of the organisation (not met)


                                                                 1
Assessment Area                                          Action required                         Lead Director     Timescale

Quality - Core Standard C21               The action plan to meet compliance with this Director of Estates        Ongoing
Healthcare services are provided in       standard is the redevelopment of the Trust.  and Facilities
environments which promote effective
care and optimise health outcomes by
being well designed and well
maintained with cleanliness levels in
clinical and non-clinical areas that meet
the national specification for clean NHS
premises (not met)

Quality - Smoke – free NHS               To further embed Trust no smoking policies and, Acting Director of       February 2007
Reducing adult smoking rates (from       in particular to improve the patient referral Nursing
26% in 2002) to 21% or less by 2010,     process to NHS Stop Smoking Services
with a reduction in prevalence among
routine and manual groups (from 31%
in 2002) to 26% or less.
The Trust should be smoke free
Smoking status in all adult inpatients
recorded
There should be an implemented
agreed management process for the
routine provision of advice and onward
referral of all adult inpatients who
smoke to NHS Stop smoking services

Use of Resources – Auditors Local        The Trust should ensure that all Trust Board         Director of Human   November
Evaluation of Financial Reporting        reports and financial reports are available on the   Resources &         2007
                                         Trust’s website to enable easy access to             Corporate Affairs
                                         stakeholders.



                                                                 2
Assessment Area                                       Action required                       Lead Director         Timescale
Use of Resources – Auditors Local    The Trust should ensure that the preparation of    Director of Human       2007/08
Evaluation of Financial Reporting    the annual report is accelerated such that it is   Resources &             Accounts
                                     available at the start of the audit process.       Corporate Affairs
Use of Resources – Auditors Local    The Trust should develop and implement a           Director of Finance     January 2008
Evaluation of Financial Management   formal cash management strategy in line with
                                     that required for foundation trusts.
Use of Resources – Auditors Local    The Trust should ensure that the key actions       Director of Finance     November
Evaluation of Financial Management   within the Trust Development Programme are                                 2007
                                     integrated into the medium term financial plan
                                     and are subsequently monitored to ensure
                                     delivery within agreed timescales.
Use of Resources – Auditors Local    The Trust should improve the budgetary             Director of Finance     Completed
Evaluation of Financial Management   monitoring and financial reporting process to
                                     ensure budget reports are produced within 10
                                     working days.
Use of Resources – Auditors Local    The Trust should ensure that the links between     Director of Finance     Completed
Evaluation of Financial Management   non financial and financial information are made
                                     more explicit through improved reporting of
                                     reported items.
Use of Resources – Auditors Local    The Trust should ensure that the fixed asset       Director of Finance     New Asset
Evaluation of Financial Management   register is updated throughout the year to allow                           register
                                     it to be an integral part of asset management                              implementation
                                     information used in managing the asset base.                               by September
                                                                                                                2008
Use of Resources – Auditors Local    The Trust should ensure that, in line with the     Director of Estates &   In place
Evaluation of Financial Management   continued changes to the redevelopment, it         Facilities              (supports
                                     develops a risk adjusted backlog maintenance                               2007/8 capital
                                     programme.                                                                 programme)



                                                            3
Assessment Area                                      Action required                        Lead Director       Timescale
Use of Resources – Auditors Local   The Trust should implement a programme to           Director of HR &       October 2007
Evaluation of Internal Control      ensure that board members and senior                Corporate Affairs
                                    managers are adequately trained on risk
                                    management.
Use of Resources – Auditors Local   The Trust should ensure that its procedure          Director if IMT        March 2008
Evaluation of Internal Control      notes for all business-critical systems are
                                    regularly reviewed and updated.
Use of Resources – Auditors Local   Board reports should evidence consideration of      Director of HR &       November
Evaluation of Internal Control      legal issues and the Trust should implement         Corporate Affairs      2008
                                    procedures to set out the circumstances under
                                    which professional legal advice should be
                                    sought.
Use of Resources – Auditors Local   The Trust should ensure that the audit              Chair of Audit         January 2008
Evaluation of Internal Control      committee performs both a self assessment of        Committee / Director
                                    its role against the audit committee handbook,      of Finance
                                    and a review of its effectiveness against its
                                    objectives.
Use of Resources – Auditors Local   The Trust needs to take action to embed the         Director of Finance    March 2008
Evaluation of Internal Control      counter fraud culture, including proactively
                                    raising awareness of the standards of ethical
                                    conduct within the Trust and the Trust’s
                                    whistleblowing policy. These procedures should
                                    be supported and promoted by non-executive
                                    directors and senior management.
Use of Resources – Auditors Local   The Trust needs to demonstrate the impact of        Director of HR &       March 2008
Evaluation of Internal Control      the communication strategy and the tailoring of     Corporate Affairs
                                    methods to reflect local needs. This should
                                    include sufficient evidence of action plans being
                                    taken to the Board and the extent to which ‘hard



                                                            4
Assessment Area                                         Action required                     Lead Director         Timescale
                                        to reach’ groups are represented.
Use of Resources – Auditors Local       The Trust should demonstrate that information    Director of Finance     Completed
Evaluation of Value for Money           presented to the Board is sufficient to assess
                                        performance in all key areas. This should
                                        include progress on the implementation of
                                        actions.
Use of Resources – Auditors Local       The Trust will need to show progress in          Director of Finance     On going
Evaluation of Value for Money           implementing action plans from internal and
                                        external reviews and that the actions flowing
                                        from these are addressed in a timely manner.
Use of Resources – Auditors Local       The Trust should demonstrate the impact of       Director of Finance     On going
Evaluation of Value for Money           efficiency plans in terms of lower costs and
                                        improved activity and quality. This includes
                                        demonstrating the achievement of actions to
                                        address the efficiency of clinical services.
Quality - Addressing Health             Overall target 90% data collected (53% 06/07     Director of             March 2008
Inequalities – data quality on ethnic   has increased to 69% in first quarter 2007/8)    Operations & Service
group                                                                                    Development /
                                        Display posters in OPD/CBU/Bolsover Street
                                                                                         Director of Corporate
                                        Incorporate into local induction                 Affairs
                                        Set up monitoring for ward clerks
                                        Ensure OPD receive ongoing feedback from
                                        Information department
                                        Ensure areas not captured by OPD are informed
                                        and monitored

Quality – Access Targets – 18 weeks     18 week access target action plan – see          Director of             See attached
                                        attached                                         Operations & Service    action plan
                                                                                         Development


                                                               5
Assessment Area                                         Action required                       Lead Director       Timescale
Quality – Access Targets – Existing    Outpatients & Diagnostics already being            Director of            March 2008
Inpatient, Outpatient and diagnostic   delivered.                                         Operations & Service
waiting time targets                                                                      Development
                                       Inpatients - 5 breaches in 2007/8 – main
                                       pressure area is spinal surgery – pay rates
                                       agreed and extra sessions being put in place to
                                       avoid future breaches.
Quality – Access Targets –             Only 1 breach this year compared to a total of     Director of            March 2008
Guarantee to admit within 28 days of   31 in 2006/07 – early warning & communication      Operations & Service
cancelled operation                    systems have been strengthened and regular         Development
                                       proactive monitoring taking place. The number
                                       of cancellations on day of admission has been
                                       significantly reduced which has also helped with
                                       this target.




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