Agenda item

Quality Report

Julie Marshman, Chief Nurse

Charlotte Forsyth, Medical Director


The Board received and considered a monthly report which provided commentary and progress on activity associated with key safety and quality indicators. The key points to note for December 2019 were as follows: -


Serious Incidents  -   A number of serious incidents had failed to be completed within the required 60 days.  This was primarily due to the availability of trained investigation leads not meeting the current demand.  It was noted that all serious incidents were always immediately reviewed with learning shared however the full investigation was over a 60 day timeframe.  A full review was currently being undertaken to look at policies, reporting, and current structure around the quality team.


Liam Coleman, Chair asked how long it would take for the proposals to be made available.  Julie Marshman, Chief Nurse replied that a report would be ready for review at the relevant Board sub committees in March 2020 followed by Board in April 2020.

Action  :  Chief Nurse


Infection Prevention and Control  -  There were 4 cases of C.difficile infection reported in December 2019, however it was noted that  the Trust was slightly under the Q3 upper limit of 36 cases for the diagnosis of C.difficile infection.


There were low figures reported in ED during December for patient equipment.  A full investigation had been undertaken and actions put in place.  It was noted that  the department had improved significantly in this area and were now fully in line with other areas’ scores.


The Trust had seen an increase of 9% in the Gram-Negative blood stream infections (BSI) which was above the national increase of 2%.  Further review and scrutiny was underway to understand and address any root cause.  It was noted that the increase accounted for a very small number (3) of patients.


The Chief Nurse gave a verbal update on Coronavirus and assured the Board that there was a clear robust process in place with daily conference with Public Health England (PHE). 


Julie Soutter, Non-Executive Director asked about the observation hubs on the news this morning and how the Trust was going to manage this request with limited space and full hospital protocol.  Julie Marshman, Chief Nurse confirmed that a request had been received however due to lack of space within the hospital this was not possible.  The Trust was well prepared with a robust policy in place for dealing with infectious diseases.  All the relevant equipment was on site and further supplies had been ordered.


Matron Audits  -  There had been some changes in the role of matrons to allow clinical time to drive improvements in this area.  The Trust was also trialling an IT solution, Perfect Ward, to support daily safety checks and audits.


Friends and Family Test  -  The response rate for Family and Friends Test had been discussed  in detail at Quality & Governance Committee.  New ideas to improve feedback would include further use in tablets and increase in text messaging.


Complaints  - Actions had been taken to be more proactively managing complaints in particular to support greater compliance within timescales.  The overdue complaints were primarily serious incident investigations or very complex cases and the number had significantly reduced.


Electronic Discharge Summaries (EDS)  -  A number of actions had been taken to improve compliance in recent months which included training, extra hours given to junior doctors, exploring IT solutions and establishing a task and finish group.  This remained an area of focus within the Quality & Governance Committee to support the required solutions to make improvements. 


Julie Soutter, Non-Executive Director asked why informatics could not provide accurate information in April 2019.    Tracey Cotterill, Interim Director of Finance responded that the system had gone down and was the reason why the Trust was given emergency IT capital funding.  Charlotte Forsyth, Medical Director added that she was confident that the data was now accurate and there were no concerns in this area.




(a)   that the quality matters and exceptions contained within the report be noted;


(b)   that it be agreed that the Quality Report provides assurance of progress towards quality improvements and quality indicators;


(c)   that the report be noted; and


(d)   that a report on the proposals following the quality governance review be received in May 2020.


Supporting documents: