West Hertfordshire Hospitals NHS Trust Improving Safety and Quality what have we done since April? Update for Oversight Group September 17 th 2015 Attachment A

West Hertfordshire Hospitals NHS Trust Delviering rapid improvement We have been working hard to deliver improvements since the Inspection in April – this reflects the priorities we had already set ourselves in our Annual Plan and the immediate verbal feedback we received from the CQC following their visit in April. We are developing an improvement plan for the next 3 / 6 / 12 months that is focused on delivering sustainable impropvements in process and outcomes. Topicslides Quality Governance and Risk Management Workforce Information Governance and medical records Estates and Health and Safety Maternity & Gynaecology Emergency Care Medicine Surgery Diagnostics and Outpatients 2 This pack summarises some of our key achievements since April 2015

West Hertfordshire Hospitals NHS Trust Quality Governance and Risk Management (1) Reviewed Governance and established new ‘Integrated Risk and Governance’ sub committee of the Board – met for first time in August. Reviewed and updated BAF – 9 principle risks identified and key assurance processes mapped. Overhauled corporate risk register – reviewed and re-scored all risks rated 15+. Reduced from >180 to 28 risks. Ongoing work to review all risks at 10 and 12 and make sure appropriate controls in place and any further actions required identified and delivery tracked. Developed a simple risk management guide for staff and begun the communications and roll out process. Reviewed and simplified SI process, introduced new 45 day review meetings for progress and lessons learned. Back log of overdue Serious reduced from 34 to 10. New complaints manager in post and addressing backlog of historic complaints.

West Hertfordshire Hospitals NHS Trust Quality Governance and Risk Management (2) Introduced new standardised quality governance reporting from divisions to Quality and Safety Group. Established quarterly external peer review visits – first visit team of 80 people did comprehensive review of Watford Hospital. Key themes fed back to divisions for action. Further roll out of ‘TEST YOUR CARE’ (monthly audit of key nursing standards) to ITU, ED and Urgent Care Centre. Business case approved for electronic tracking of medical records – programme commences end September.

West Hertfordshire Hospitals NHS Trust Workforce Implementing Trust wide recruitment and retention plan – offeres made to 170 Phillipino nurses + 35 nurses from Europe. Goal is to have 120 new recruits from overseas in post by end Nov. Listening into Action Launched – 3 Big Conversations held (one at each hospital site) plus targeted sessions with clinical leaders, more than 200 staff engaged. Additional session held on recruitment and session planned on finance and efficiency. 10 clinical programmes of work launched plus 5 enabling our people schemes. Programme of work to improve staff facilities agreed – staff garden created, hot food trolley introduced to key clinical areas (e.,g. theatres) water coolers and vending machines being installed, staff area created in restaurant ~ more improvements planned ! Updated Trust Induction programme to include mandatory training - “passport to practice” New simplified appraisal paperwork developed. Formal review of NHS P contract and performance improvement plan developed. Reviewed all Exec Director files in accordance with Fit and Proper Persons.

West Hertfordshire Hospitals NHS Trust Recruitment Overview 6 Number of Joiners Aug-14Sep-14Oct-14Nov-14Dec-14Jan-15Feb-15Mar-15Apr-15May-15Jun-15Jul-15 Total N&M Number of Offers Aug-14Sep-14Oct-14Nov-14Dec-14Jan-15Feb-15Mar-15Apr-15May-15Jun-15Jul-15 Total N&M OffersJoiners

West Hertfordshire Hospitals NHS Trust Estates and Equipment Validation of all theatre ventilation systems will be complete by Friday 18 th September Mortuary security and flooring complete. External validation of pressure levels by mid October. Air pressure levels good. Updated H&S policy for contractors and out to advert for site contractor manager (currently filled by agency). Weekly audits of security and fire doors by porters and security staff. Ward and department based fire training programme being rolled out. Medical Equipment system updated. Review of pathology, radiology and loan equipment and processes underway. New secure confidential waste bins purchased.

West Hertfordshire Hospitals NHS Trust Maternity and Gynaecology Closed private obstetric service Appointed new Associate Medical Director for Obsetrics and Gynaecology to provide additional expert leadership to the service for 12 months (Mr. Greg Ward – Head of O&G at Croydon Hospital and Head of Specialty forr O&G at the London Deanery.) Appointed new Clinical Director across O&G – effective September Strengthened Midwifery leadership – interim Head of Midwifery on secondment from RFH for 6 months pending substantive recruitment. Recruited into 2 senior midwifery leadership posts. Consultant lead for labour ward appointed. Consultant ‘hot days’ to provide more senior presence and continuity on labour ward now in place (98 hours cover) Recruited new O&G consultant. ‘Local Onion’ meeting held with O&G theatres and labour ward staff to give staff an opportunity to discuss the issues.

West Hertfordshire Hospitals NHS Trust Emergency Care Implemented clinical streaming at Watford – weekly data review demonstrates 99% performance. Fully recruited to all middle grade posts within department. Created 4 new paediatric ED posts providing additional 28 sessions of consultant cover. One additional adult Consultant recruited providing additional 4 sessions of consultant cover. Agreed plan with CCG to introduce GP led urgent care model of children with primary care needs. Positive Trauma network peer review visit in August. Comprehensive dashboard and data set for ED developed and regularly reviewed via departmental meetings and emergency care improvement programme. (See QS data pack for summary performance data) Introduced queue nurse and significantly reduced delays in ambulance handovers. (see QS data pack) Major Incident Plan updated and communications and training plan agreed and being rolled out.

West Hertfordshire Hospitals NHS Trust Medicine Sarratt Ward nursing leadership strengthened, vacancy rate significantly reduced and ‘perfect operational ward’ project implemented and demonstrating improvements including reduced length of stay. Resolved issues re model of care for non invasive ventilation (NIV) patients New clinical leadership in respiratory, immediate improvements made to outpatient booking and scheduling, external review commissioned – formal report and recommendations due to be received in October. New Consultant appointed. Increased ward adminstrative support to medical wards. Reduced length of staf for non DTOC patients. Improved number of patients ‘home before lunch’ – now one of best performing trusts in the patch. (See QS data pack)

West Hertfordshire Hospitals NHS Trust Surgery Delivering national RTT standard for incomplete pathways (See data pack) Significant improvements in Cancer performance (see data pack) Positive peer review feeback for Trauma care (August) Siginficant reduction in back log of complaints – currently 7 open complaints within the division. Introduced weekly theatre onion for Watford Theatres with sessions also held at St Albans and Gynae theatres.