Annual Report 2004-2005: Clinical Governance
- Clinical Governance
- Risk Management
- Clinical Negligence Scheme for Trusts (CNST)
- Complaints and Comments
- Independent Review Panel Requests (IRP)
Download the Trust's 2004/05 Annual Report
Download a printable version of the Trust's 2004/05 Annual Report
Clinical Governance - it's everybody's business
Clinical Governance focuses on the activities involved in delivering high quality care for patients. A revised Clinical Governance Strategy covering the period 2004-2006 was produced and includes:
- raising the level of patients' satisfaction with their standards of care and ensuring it is delivered in a secure, clean, comfortable and well-maintained environment
- taking a total risk management approach, considering both clinical and non-clinical risk
- producing useful, accurate and timely information for both patients and staff
- making best use of the available evidence base to improve the services offered
- engaging constructively with the StHA, PCTs and other external partners in ways which help to improve the patients’ experience of care.
For more information please contact Celia Richards, Clinical Governance Manager on 01442 287260 or email celia.richards@whht.nhs.uk
Risk Management
During the past 12 months, risk management has focused on two principle areas; the implementation of the Datix system and the integration of the new incident report form. These two areas have become inextricably linked, as the Trust pushes forward with embedding a formal risk management system. Mandatory training sessions have raised the importance of incident reporting to all staff – a fact highlighted by a significant increase in incident reporting from 2808 in 03/04 to 7445 in 04/05.
The Trust-wide use of an electronic risk management database is also enabling the tracking of progress with incident investigation and ensures that both staff and the organisation as a whole learn from incidents and from near misses. The proportion of incidents actually being closed has risen from 40.9% last year, to a current figure of 82%.
Clinical Negligence Scheme for Trusts (CNST)
The Trust’s Maternity service was assessed in November for CNST Level 1 and achieved exceptional results with overall compliance of 98.7%. Maternity is scheduled to undergo assessment at Level 2 in February 2006, back to back with the Acute Services Level 1 reassessment.
Complaints and Comments
The Trust takes patients’ feedback very seriously and uses it as an opportunity to learn lessons and improve our service. During the past year the Trust received a total of 632 formal complaints. Seventy-five percent of those patients or relatives making complaints received a response within 20 working days. The Trust’s Patient Advice and Liaison Service received 1,232 calls and/or visits and resolved 83% (1,027) of these, passing the outstanding 17% to be answered as formal complaints.
From the issues raised in complaints, measures are identified and action taken to rectify, improve or prevent the risk of reoccurrence. Changes that have been implemented in the last year include:
- Reintroduction of a hot food trolley in the Rapid Assessment Unit at Hemel Hempstead
- Phlebotomy patients are now being asked to complete a questionnaire in order to obtain their views on the services provided
- Layout of hospital site maps has been reviewed and new maps produced
Independent Review Panel Requests (IRP)
Following the implementation of the revised NHS Complaints Procedure, the Health Care Commission assumed responsibility for Stage Two of the process in August 2004. The information provided includes requests made to the Health Care Commission. The Trust received nine new IRP requests between April 2004 and March 2005. Of these, one request was declined, and one panel was granted and held with a report issued.
