Clinical Governance Department Annual Report 2002-2003

Clinical governance is about taking corporate responsibility for performance and providing the highest possible standard of clinical and social care.

Green Park Healthcare Trust has been committed to this concept for some time and has been proactive in pursuing best practice and setting new standards in clinical governance in Northern Ireland.

New Appointments

In 2002 the Clinical Governance Department appointed the following new posts:

Risk Management

New Accident/Incident/Near Miss forms were introduced across the Trust and combined with training in incident reporting. As a result the number of accidents, incidents and near misses reported has increased by 24%(378), allowing trends to be identified and monitored.

A Health & Safety Consultant, in conjunction with the Occupational Health Department and the Litigation Manager, undertook 5 departmental inspections. All were followed up with reports for action.

Six editions of a Health & Safety Bulletin were published, updating staff on topical safety issues.

Complaints and Compliments

In the year 2002-2003 the Trust received 165 complaints and 3,069 compliments.

This represents a 29% (68) decrease in the number of complaints from the previous year.

All complaints were acknowledged within 2 working days and 163 complete responses (98% of complaints received), were distributed by the Chief Executive within the recommended 20 working days.

Controls Assurance

Of the 21 Controls Assurance Standards, fourteen have been completed and the remaining standards are on course for completion on time.

Research and Development

The Trust appointed a Research & Development Manager to ensure all research incorporates the principles of good practice as outlined in the document “Research Governance Framework for Health and Social Care”, Department of Health.

Evidence-based Practice

During the year nine clinical areas were reviewed. The Trust evaluated existing clinical practice against recommended standards of care. Practice must be based on sound evidence and yet still delivered to supply local needs.

A full list of reviews is available in the Clinical Governance Annual Report 2002 –2003. For further information contact The Clinical & Social Care Governance Dept, McKinney House, Musgrave Park Hospital, Stockman’s Lane, Belfast, BT9 7JB, Tel 028 9066 9501.

Nursing Quality

During 2002/2003 eleven “Monitor” assessments were undertaken in the Trust and action plans submitted for follow up.

High standards of care were attained (in Meadowlands 1,2, & 3, Rheumatology 5, Withers 2 & 5, Spinal Cord Injuries Unit, Forster Green Wards 3 & 4, Theatres and High Dependency Unit) with an average score of 97% for patient-centred care and 94% for ward management.

A Patient Diary initiative from the Commission for Health Improvement, was undertaken in Withers Orthopaedics 2 & 5 and in Rheumatology 5. Feedback was very positive and complimentary to staff of all disciplines.

Multi-professional Audit

In 2002-2003 twenty-one multi-professional audits and six re-audits were completed in the Trust.

New patient surveys were piloted with inpatients, outpatients and private patients. Trust Volunteers assisted patients to complete the questionnaires and ensure a higher degree of objectivity. They also provided support in areas where patients required assistance to complete the documentation.

Acknowledement

The staff in Clinical Governance would like to express their appreciation for the support and guidance of Dr Denis Connolly, Medical Director, and Mrs Eleanor Hayes, former Director of Patient Services during 2002-2003.