Appendix C

QUALITY 3 TO 3 MEETING

GUIDANCE NOTES

QUALITY REPORT TEMPLATE (Report over the last quarter)

The purpose of the quality 3 to 3 meeting is for the DMT to provide assurance that patients are receiving good quality care backed up by relevant outcome measures or quality indicators. It is important to provide a balance of good practice but also of concerns and actions being taken to address them and to ask for advice and help from the Executives if needed.

The meeting will be joined by the Heads of Clinical Effectiveness and Risk Management. The DMT are expected to present their own information supported by the Heads attending the meeting. At the end of the meeting actions will be agreed and minuted on the quality report or in the Directorate 3 to 3 minutes. In addition, there must also be a record of the discussions on the 3 to 3 minutes regarding new risks that have been added to the Directorate Risk Register and if any of these risks require inclusion onto the Trust Risk Register. This is to ensure compliance with the Trust Risk Management Strategy and provides evidence required for both internal and external assurance of risk management within the Trust. Both the minutes and the quality report should be circulated after the meeting and copied to the people sited at the end of the report.

The DMT are expected to provide a quality report in advance of the meeting with concise information. A small pack of information is best to ensure focus is maintained on the key issues. Set out on the following pages is a reporting template with data sources which the DMT can access to demonstrate outcomes, safety and patient experience to provide quality assurance.

The only additional information that needs to be attached to the report is:

  • Hand hygiene audit
  • Risk management report card
  • Risk register
  • Executive safety and quality walk rounds
  • Complaints numbers and themes report
  • Either Directorate dashboard (could be displayed at the meeting) or Directorate quality indicator or measures card.
  • Directorate real time feedback report (run charts)
  • Other report only by exception

X DIRECTORATE

QUALITY 3 TO 3 MEETING

QUALITY REPORT

Date

1.0Introduction

This report sets out the Directorate quality activity since X to assure the quality, safety and effectiveness of patient care and continuous improvement.

2.0Salisbury Organisational Trigger Tools (SOTTs)

Speciality/Trigger / Last review / 0 / 1 / 2 / 3 / 4
quarterly
quarterly
quarterly
quarterly
quarterly
quarterly
quarterly
quarterly
quarterly
quarterly

Only provide commentary on triggers of 0 or 1 and what action is being taken or help needed to improve.

2.1 Care Quality Commission (CQC)

Provider compliance assessment (PCA) Outcomes 1 - 28
Report exceptions based on CQC risk profile

3.0Patient safety

3.1Infection prevention and control practice / Data source
Outcomes:
  • X Cases of MRSA or MSSA bacteraemia
  • X Cases of C Difficile
  • Surgical Site infections
  • Any other infection issue eg ESBL UTIs, Legoinella, E Coli
Practice issues compliance:
Hand hygiene – raise areas of concern
Bare below the elbow and uniform compliance
Commode cleanliness and taping practice
MRSA screening, pathway compliance of last audit
Isolation risk assessment tool
Cleanliness & PEAT
Any other concerns / Ward KQI
IPCT reports
MM minutes
IPCT
DSN
DSN
Audit report
DSN
C4C/PEAT reports
3.2 Patient safety programme
Comment on progress with practice such as catheter care bundle, peripheral cannula care bundle, ventilator acquired pneumonia.
Stop moment in theatre, WHO surgical checklist
Falls resulting in harm, including RCAs and actions taken to reduce the risk.
VTE risk assessment and prophylaxis compliance
Pressure ulcers / Directorate representatives
Risk report card
Ward KQI
3.3 Safeguarding (adults and children)
Report exceptions / Safeguarding report
3.4Controlled Drugs report
Report exceptions

4.0Mortality (data is available on HAL & Directorate Dashboards via service directory)

11/12 / April / May / June / July / Aug / Sept / Oct / Nov / Dec / Jan
12 / Feb / March / Total
Speciality
Speciality
Speciality
Speciality
Speciality
Total

Comment on:

The total number of deaths & percentage against the denominator in the Directorate compared to the previous year.

Speciality mortality reviews and learning or practice of concern.

Dr Foster’s mortality data report if recently published. Any red flags

5.0Clinical Effectiveness

5.1Key quality indicators and measures / Data source
Indicators:
Specific indicators relevant to Directorate eg stroke, hip fracture
Ward quality indicators – report exceptions
Comment on practice concerns & actions taken to improve / Directorate dashboard or Key quality indicator report
Ward quality indicator report
5.2Progress against relevant NICE guidance, NCEPOD,
National Confidential Enquiries and the NICE Quality Standards
Comment on Directorate relevant guidance/standards/reports.
Comment on Trust wide relevant guidance – Dementia and End of Life Care.
In particular identify needs for data collection, measurement assistance / Clinical Governance Administrator or Clinical lead
5.3 Clinical Audit
Comment on:
Progress against national audits and actions taken to improve.
Progress of local audit activity.
Progress of Trust wide audits – consent, medical records, discharge summaries / OSCA reports
Clinical Audit Facilitator or Directorate link
5.4 Audits for contract requirements/CQUIN
Discharge summary completeness progress and actions taken to improve
Discharge summary sent to GP within 48 hours
OPD letters to GPs within 7 days
EDDs for elective and emergency inpatients
Fractured NOF pain relief – Medicine
LCP audit
Dementia audit
Unplanned returns to theatre - Surgery / Project Manager, Operations Directorate
MSK Clinical Audit Facilitator
Chair of EOLCSSG
Dementia Strategy lead
Clinical Audit
5.5Research and Development / Data source
Study participation
Number and type of studies participating in
Outcomes if known
New procedures required / Head of R&D

6.0Patient Experience

6.1 Delivering Same Sex Accommodation / Data source
  • Non clinical breaches, reasons and action taken to address
/ Surgical Directorate support Manager
6.2Directorate Real Time feedback
Comment on the trends and actions taken in response
Copy and paste some of the RTF feedback into this report and any
action taken to address concern or perhaps a patient story (short). / Directorate RTF run chart
PPI
6.3 National Inpatient Survey action plan
Comment on the issues and actions taken to address them. / Directorate report
Head of PPI
6.4 National Outpatient Survey action plan
Comment on the issues and actions taken to address them / Directorate report
Head of PPI
6.5 Compliments, comments, complaints and concerns
Comment on numbers & response times. Themes arising and action taken to address them. The complaints the DMT are most concerned about. / Directorate report
Head of Customer Care
6.6 Patient and Public involvement
Comment on focus groups, patient surveys and actions as a result / Directorate report
Head of PPI
6.7 Patient Reported Outcome Measures (PROMS)
Comment on participation rates, health gain post surgery and benchmark against the national position / HES on line

7.0Service improvement

7.1Directorate and cross Directorate projects / Data source
Enhanced recovery programmes / Trust activity & performance report
Productive ward/operating theatre / Ward report to NMF
RTRTRP reducing length of stay, rapid discharge, avoiding re-admissions / Trust activity & performance report

8.0Risk management

8.1 Risk Management report card / Data source
Comment on number of type of incidents, particularly catastrophic and major incidents and work being undertaken to address.
Comment on any incidents of high number, the reasons for these and work being undertaken as a result.
Any never events / Risk card
8.2 Serious incident Inquiries/Clinical reviews/Local reviews
Comment on inquiries and reviews and the progress of recommendations. / Risk card
8.3 Risk Register
Comment on risks over 12 and decide at the meeting if they need to be on the corporate risk register.
Flag up any new risks over 12 / Risk register

9.0Learning and Development

9.1 Leadership/staff development
Comment as appropriate

10.0Clinical Governance Committee and Clinical Management Board items to be progressed by Directorates

10.1 Clinical Governance Committee / Data source
Comment on progress of items attributed to Directorate that require monitoring / CGC minutes & tracker
10.2 Clinical Management Board
Comment on progress of items attributed to Directorate that require monitoring
Eg progress of National Continence audit / CMB minutes & tracker
11.0Any other quality concern

12.0 Quality meeting action plan

At the end of the meeting document items that need to be progressed by the next meeting

No / Action / By who / By when / Progress tracker at next Quality meeting

Copy to:

Director of Nursing

Deputy Director of Nursing

Medical Director

Chief Operating Officer

Head of Clinical Effectiveness

Head of Patient and Public Involvement

Head of Customer Care

Head of Risk Management

Head of Service Improvement

Deputy Director of Human Resources

Head of Learning and Development