Privacy and dignity eliminating mixed sex accommodation improvement plan dec 2009 version 7
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Privacy and dignity eliminating mixed sex accommodation improvement plan dec 2009 version 7 Privacy and dignity eliminating mixed sex accommodation improvement plan dec 2009 version 7 Presentation Transcript

  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 – March 2010 Central Manchester University Hospitals Foundation Trust (CMFT) is committed to providing the best possible accommodation for patients, which respects patients’ need for privacy and dignity and enables safe and high quality care to be provided. This action plan focuses on maximising access to single sex facilities, maximising patients’ privacy and dignity, and reassuring patients that everything possible has been done. Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date 1. The board of Ensure that the The Quality Strategy sets out Associate Ongoing Quality Campaign launched May 2009 directors actively board is fully aware the work programme on Director of support patient’s of the privacy & privacy and Dignity under Patient privacy & dignity: dignity agenda the work stream of Patient Services 1.1 There is clear Experience and has been evidence of endorsed by the Board of commitment by Directors in March 2009 the board of directors to improve privacy To publish the As part of CMFT’s Lead Ongoing The Trust Eliminating Mixed Sex and dignity Trust’s commitment to improving Nurse, Accommodation Improvement Plan and arrangements commitment in communication with patients Privacy & progress to date, is available on the Trust’s ensuing privacy & and the public our website is Dignity website for members of the public to dignity of all its continually being developed access. local population and the Trust is planning to and service users Completed CMFT Privacy and Dignity web page develop a webpage specifically relating to Lead signed off and available on the Trusts privacy & dignity, as a Nurse, website from December 2009 for members means of providing Privacy & of the public to access at information to patients, Dignity www.cmft.nhs.uk/trust/privacy-and-dignity visitors and service users 1/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date 1.2 The board of Ensure that the The trust is currently Associate Completed Implementation of the Dr Foster PET data directors patient experience implementing the use of the Director of collection system for patient experience understands what is paramount and Dr Foster Intelligence's Patient completed for all in patient clinical areas. patients want and the board is fully Patient Experience Tracker Services endeavours to aware of what (PET) an electronic patient Patient feedback on privacy and dignity deliver it patients want by feedback system to enable questions to be one of series of monthly analysing the patients to feedback their themes in relation to patient experience information experience. Patients will be collected via newly implemented PET tool. gathered from asked questions pertaining Privacy and Dignity feedback to be patient experience to privacy and dignity weekly collected every 6 months as part of rolling surveys, for a period of one month programme. Initial data collection complaints and every 6 months. undertaken in July/August 2009. Next data incident reports collection via PET devices due January/February 2010. Ongoing work with Dr Foster to address data input challenges and with ward teams to ensure appropriate coding and sample size is obtained. Patient experience metrics for intelligent board agreed currently developing format for presentation with Trust. The board of directors will Associate Ongoing Initial phase of Leadership walks commence a series of Director of commenced in June 2009, with a plan to leadership walks from July Patient undertake walks in 60 clinical areas across 2009 to gain direct patient Services the Trust during the first year of and staff feedback and implementation. directly observe aspects of the patients’ experience which include privacy and dignity. Version 7 – December 2009 2/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date 1.3 The board In line with the Monitoring feedback in Associate From Patient feedback on privacy and dignity understands the Trust’ Quality terms of privacy and dignity Director of June questions to be one of series of monthly trust’s Campaign to agree from the Dr Foster Patient 2009 themes in relation to patient experience performance objectives for Intelligence's patient Services / onwards collected via newly implemented PET tool. against privacy improvement, that experience tracker (PET) Lead Privacy and Dignity feedback to be and dignity have been Nurse, collected every 6 months as part of rolling benchmarks and identified through Privacy & programme. Initial data collection sets local goals for local and national Dignity undertaken in July/August 2009. Next data improvement benchmarking collection via PET devices due January/February 2010. Ongoing work with Dr Foster to address data input challenges and with ward teams to ensure appropriate coding and sample size is obtained. Patient experience metrics for intelligent board agreed currently developing format for presentation with Trust. Monthly analysis and Lead Ongoing Data collated via Ward Managers and monitoring of information Nurse, Monitor Matrons ward rounds reviewed at monthly gathered from the Privacy & Monthly privacy and dignity meetings and Matron/Ward Manager ward Dignity appropriate actions identified. round framework. Establish a board Quarterly reports to the Director of Jan/Feb Board reports received June and August reporting Board on privacy and dignity Nursing 2010 2009.. framework to (adults) enable feedback to the board on Development of the Associate First phase of leadership walks privacy and dignity leadership walks Director of Dec commenced and will continue on a rolling to take place Patient 2009 programme. Review of this process Version 7 – December 2009 3/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date Services framework and how it links with the Matron Ward Round and Patient Experience Tracker (PET) to be discussed and patient experience metrics for intelligent board agreed currently developing format for presentation with Trust. A monthly mechanism to capture patient experience in relation to privacy and dignity is established. Data capture tools have been amended to enable areas to identify where an incident of ‘mixing’ has occurred. This will enable monitoring of the provision of same sex accommodation in line with the Trust policy and will inform future work streams. 1.4 Resources are To allocate and A building and refurbishment Director of Ongoing Privacy & Dignity - Eliminating mixed sex allocated to monitor use of programme is underway for Nursing accommodation (PDEMSA) meetings held preserving and resources identified the older hospital buildings (adults) monthly to review progress and establish improving the to ensure the concentrating this year on: / Associate actions. privacy and dignity privacy & dignity of Director of of all patients and all patients and • Medical Assessment Estates & Completed Capital refurbishment programme in service users service users Unit (MAU) Facilities/ progress: • Emergency Surgical Head of • Medical Assessment Unit refurbishment Unit (ESU) Nursing completed and opened 26th November 2009. • Endoscopy unit has moved to same- sex lists from November 2009. To ensure that A rolling programme of Associate Surgical Division reconfiguration - clinical providers improvement works is Director of scheduled refurbishments works extended have undertaken a planned with PFI partners as Estates and to incorporate life cycle work such as self assessment of part of the life cycle works facilities/ replacement of ceiling, floors and Version 7 – December 2009 4/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date their current for the hospitals Head of redecoration of these clinical areas. position in relation Nursing • Emergency Surgical Unit to complete to mixed sex March 2010 – becoming same-sex wards, accommodation March located on Ward 1 and Ward 2. and produced an 2010 • Renal transplant & Urology improvement plan refurbishment scheduled to complete as part of their August 2010 - becoming same-sex wards, plans indicated by August located on Ward 9 and Ward 10. the SHA 2010 The New Hospitals are fully Associate Complete compliant with the guidance Director of on mixed sex Estates and accommodation Facilities 2 The physical To monitor the The development and Associate Ongoing Ward Manager/Matrons ward round environment Trusts implementation of the Director of framework captures standards in relation to actively supports performance in Matron/Ward Manager ward Patient cleanliness and infection prevention and patients’ privacy relation to round framework in January Services/ control. Review of Matron/Ward Manager & dignity cleanliness and 2009, ensures that patients’ Corporate Ward Round framework undertaken in 2.1 The care infection experience and patients’ Lead Nurse August and revised elements included in environment is prevention and environment are evaluated relation of essence of care, patient safety, clean and well control and is critical to continually and valuing patients. Process to monitor maintained improving our performance. and review improvements being established for implementation from January 2010. To respond to Ward rounds are undertaken Lead Ongoing Department of Health, Privacy and Dignity staff, patients and weekly, with specific focus Nurse, Environmental Audit undertaken June 2009 the public when on the environment on a Privacy & which identified three areas as non- the environment of fortnightly basis. The results Dignity compliant in relation to the environment of care falls below and actions to address any care: acceptable identified issues are collated Version 7 – December 2009 5/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date standards and electronically • Clinical Decisions Unit (CLDU) demonstrate • Programmed Investigations Unit continuous (PIU) improvement • Discharge Lounge Ongoing discussions in relation to options for these areas are taking place via monthly mixed sex accommodation meetings. Interim local policies are being developed supported by patient information. Patient information leaflets developed and Complete implemented. The cleaning and Associate Ongoing maintenance of the estate is Director of the responsibility of our Estates and subcontractors Sodexo Facilities Healthcare and Sodexo FM and is monitored by the Trust monitoring team 2.2 There is good To repeat a Trust To scope issues relating to Lead Completed The Institute for Innovation and physical wide audit using mixed sex accommodation. Nurse, Improvement Self Assessment Checklist separation of the Institute for Privacy & Audit completed in August 2009 for all sleeping Innovation and Dignity areas providing patient care. accommodation for Improvement Self men and women Assessment Analyse and present the Lead Results from the self assessment audit Complete Checklist, designed findings and oversee Nurse, collated electronically. Preliminary results to measure individual action plans Privacy & circulated to the Heads of Nursing and practice against Dignity / Assistant Directors of Nursing for eliminating mixed Heads of appropriate actions as required in sex Nursing/ October/November 2009. accommodation. Assistant Director of Action plans to be developed by 14th Jan 2010 Nursing December 2009, reviewed and monitored Version 7 – December 2009 6/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date by Privacy and Dignity Eliminating Mixed Sex Accommodation meeting DoH principles for Agree Trust wide standard Lead Jan 2010 Signage design developed and currently delivering same for signage to bay/ward Nurse, under consultation. sex areas. Privacy and accommodation Dignity (Sept 09) state that on mixed-sex wards bay areas should be clearly designated as male or female accommodation. 2.3 The physical To repeat the Trust Present findings of the Lead Completed Areas for improvement identified and from environment is wide scoping scoping exercise and Nurse, privacy & dignity environmental audit appropriate for the exercise in relation oversee individual action Privacy & undertaken in June 2009. care group to types of plans, ensuring that all Dignity accommodation patients are cared for in the that are used for most appropriate setting for Completed Patient information leaflet: Same-sex particular care their need, giving due accommodation – ‘we’re making groups and the consideration of their privacy improvements so you’ll feel more appropriateness & dignity comfortable’ developed. Distributed within Trust via Heads of Nursing/Lead Nurses. Available on the Trusts internet for access by the public and service users Completed ‘Pathway specific’ patient information leaflets now developed for:  Emergency surgery pathway  Elective surgery pathway  Critical Care – Intensive Treatment Unit (ITU) and High Dependency Unit Version 7 – December 2009 7/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date (HDU)  Programmed Investigations Unit (PIU)  Clinical Decisions Unit (CLDU)  The Discharge Lounge Final versions to Trust Information Group (TIG) for approval and in use by December 2009 2.4 There are To ensure Where wards have mixed Heads of Complete Results from the self assessment audit segregated toilet designation of gender patients being cared Nursing collated electronically. Preliminary results and washing single sex toilets for in different bays within a & circulated to the Heads of Nursing and facilities and washing ward footprint, ensure that Lead Assistant Directors of Nursing for facilities in clinical the allocation and signage by Nurse, appropriate actions as required in areas gender is in place for toilet Privacy & October/November 2009. and washing facilities Dignity Monitor as part of the Jan 2010 Action plans to be developed by 14th Matron/Ward Manager ward December 2009, reviewed and monitored rounds by Privacy and Dignity Eliminating Mixed Sex Accommodation meeting 3. Individual staff To ensure that the CMFT is currently reviewing Lead Complete CMFT has a ratified policy: ‘Provision of actions actively Trust has the and revising the privacy & Nurse, Same Sex Accommodation’ which support privacy & appropriate policies dignity policy in line with Privacy & incorporates national guidance for dignity and procedures in national policy for delivering Dignity delivering same sex accommodation 3.1 Staff are aware of place and same sex accommodation (DSSA). and abide by embedded to (DSSA) policies ensure that the established to privacy & dignity of Once this policy has been Implementation of policy will take place in Complete ensure privacy & patients is ratified it will be available on Lead September / October 2009 as follows: dignity considered and the Trust’s website to enable Nurse, • Widely circulated throughout the Trust maintained service users to view Privacy and • Presented at Ward Manager/Lead Dignity Nurse Forum – Oct 2009 Version 7 – December 2009 8/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date • Staff Awareness via team brief – Nov 2009 and ‘insight’ staff newsletter – Dec 2009 • Available on Trust intranet for staff and Internet by the public & service users – Oct 2009 • Incorporate into Corporate Mandatory Training Programme – Dec 2009 Bedside curtains redesigned Heads of to include “Stop – Do Not Nursing Ongoing Completed implementation within adult Enter” signs integral to the Surgical in patient areas. This design of fabric. curtains has been implemented in the new hospital development. Curtains for the new hospital Lead build will include this design, Nurse, Ongoing NHSII audit feedback will identify areas for as will all new curtains Privacy and new curtains during next phase. ordered for wards and Dignity Work ongoing to develop a specific privacy, departments. dignity and respect policy which will be launched in December 2009. Privacy and dignity issues go Completed beyond the elimination of Lead As part of the Trusts ‘Quality Strategy’, mixed sex accommodation Nurse, CMFT is working in partnership with the and the policy and action Privacy & Royal college of Nursing (RCN) to promote plans will recognise this and Dignity and embed their ‘Dignity’ Campaign’ – set out plans for Quality Delivering Dignified Care and identifying improvement including, Campaign ‘dignity champions’ information for patients, Manager / 53 staff members of staff have been trained attitude and behaviour Head of as ‘dignity champions’. Nursing - Completed Medicine As part of the Quality campaign – ‘Brilliant Basics’ the Privacy Dignity and Respect Version 7 – December 2009 9/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date launch was held on Friday 27th November 2009. With over 100 in attendance, the Trust was able to engage both staff and key external partners on our progress to date and allowed the dignity champions to celebrate and share best practice 3.2 Staff apologise for To ensure that the CMFT is to devise patient Lead Complete CMFT has a ratified policy: ‘Provision of all episodes of appropriate policies information leaflets for both Nurse, Same Sex Accommodation’ which mixing, and keep and procedures in planned/elective care Privacy & incorporates national guidance for patients and place and pathways and Dignity delivering same sex accommodation visitors informed embedded to unplanned/emergency care (DSSA). The policy includes clear about actions that ensure that the pathways. These leaflets will escalation processes and actions staff are are being taken to privacy & dignity of fully inform patients and required to take should incidence of non solve the problem patients is visitors of the provisions of compliance occur. Any incidents are considered and their care environment, investigated in line with the Trust Risk maintained. giving due consideration of Management Policy. their privacy & dignity Lead Weekly report from incident reporting Nurse, Ongoing system established to Lead Nurse for Privacy & Privacy & Dignity and Assistant Director of Dignity Nursing (Adults) to provide monitoring mechanism for policy standards. Any occurrence of Analysis and monitoring of Ongoing Ward managers and matrons ward round mixing is reported incidents data relating to Lead data now capture from patients who through the mixed sex accommodation Nurse, feedback they have been cared for in electronic incident Privacy and ‘mixed sex’ accommodation the location of reporting system Dignity this. This data is reviewed at monthly and investigated. privacy and dignity meetings. Working with Communications Team to Completed develop article for the Trust’s magazine ‘Insight’ to increase staff awareness of Version 7 – December 2009 10/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date policy and Trust improvement plan. Completed Article planned for ‘Quality Matters’ trust quality newsletter and web update via the Quality web site to take place December 2009. Jan 2010 Article planned in January patient safety and risk management newsletter ‘Lesson Learnt’. 3.3 Staff report To ensure that the Analysis and monitoring of Lead Ongoing CMFT has a ratified policy: ‘Provision of episodes of appropriate policies incidents data relating to Nurse, Monitoring Same Sex Accommodation’ which mixing through the and procedures in mixed sex accommodation Privacy & incorporates national guidance for appropriate place and Dignity delivering same sex accommodation channels embedded to (DSSA). The policy includes clear ensure that the escalation processes and actions staff are privacy & dignity of required to take should incidence of non patients is compliance occur. Any incidents are considered and investigated in line with the Trust Risk maintained. Management Policy Any occurrence of mixing is reported Weekly report from incident reporting through the Ongoing system established to Lead Nurse for electronic incident Monitoring Privacy & Dignity and Assistant Director of reporting system Nursing (Adults) to provide monitoring and investigated mechanism for policy standards. Ward managers and matrons ward round Ongoing Monitoring data now capture from patients who feedback they have been cared for in ‘mixed sex’ accommodation the location of this. This data is reviewed at monthly privacy and dignity meetings Version 7 – December 2009 11/12
  • Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009 Best Practice Expectations Outcome Lead Target Progress to Date Person(s) Principle Date Complaints and PALS Associate Ongoing information analysed Director – monthly Patient Services Matrons/Ward Manager Lead Nurse Ongoing ward rounds to access Privacy & patients views Dignity Feedback from the patient Associate Jan experience tracker (PET) in Director of 2010 relation to privacy and Patient dignity to be analysised and Services actions agreed where issues have been identified. Board of directors receive Director of Reporting framework under development in information through the Informatics order to report patient experience indicators intelligent board reports – & Associate for nursing, such as privacy and dignity on patient experience Director of regular basis to the Board. Patient indicators Patient experience metrics for intelligent board Services agreed currently developing format for presentation with Trust. Version 7 – December 2009 12/12