NHS Kirklees Update on action plan May 2009 Mixed Sex accommodation Action Plan 2009/10 1. Introduction 1.1 One of the significant challenges for the NHS in 2009/10 is to eliminate, with few exceptions, mixed sex accommodation, achieving the standards set out in the 2008/9 operating framework “to reduce mixed sex accommodation and maximise privacy and dignity in situations where the need to treat and admit takes precedence over complete segregation” 1.2 This standard is restated in the 2009/10 Operating Framework and supported by a recent letter from the Chief Nursing Officer (Appendix 1) ‘PCTs are expected to work with their local providers to deliver substantial and meaningful reductions in the number of patients in acute, general or community hospitals who report that they share sleeping or sanitary accommodation with members of the opposite sex. In deciding what constitutes a ‘substantial and meaningful’ improvement, PCTs are expected to take close account of local patient and public expectations’. 1.3 The standards for Mental Health Trusts were set out in Safety, privacy and dignity in mental health units. Guidance on mixed –sex accommodation for mental health services (NHS Executive 1999) . 1.4 NHS Kirklees is committed to show understanding, dignity and respect for all our clients, partners and staff. This is the foundation for high quality care which we as commissioners will deliver for our community. 1.5 Working with our partners which include Calderdale and Huddersfield Foundation Trust, Mid Yorkshire Hospital Trust , South West Yorkshire Mental Health Trust and Kirklees Community Health Services, we will work together to implement a robust plan for eliminating mixed sex accommodation. 1.6 As commissioners, we will through the clinical quality boards, drive this agenda forward, holding providers to account for the elimination of mixed sex accommodation and incentivising good practice through the CQUINS process We will also engage with patients and the public to understand their needs and to consult on future developments .This includes the development of our community hospital, where privacy and dignity is central to the design of the new premises. 1.7 Monitoring the implementation of Trust action plans across the health economy in partnership with NHS Calderdale and NHS Wakefield District will mean a partnership approach to monitoring through the clinical quality boards and the contract management board reporting to the NHS Kirklees Board progress toward eliminating mixed sex accommodation.
2. What should we be delivering 2.1 Men and women should not normally have to share sleeping accommodation or toilet facilities. Irrespective of where patients are, staff should always take the utmost care to respect their privacy and dignity. Single-sex accommodation can be provided in: •
Single sex wards (i.e. the whole ward is occupied by men or women but not both);
•
Single rooms with adjacent single-sex toilet and washing facilities (preferably en-suite);
•
Single-sex accommodation within mixed wards (i.e. bays or rooms which accommodate either men or women, not both; with designated single-sex toilet or washing facilities preferably within or adjacent to the bay or room).
When mixing men and women is unavoidable every reasonable effort should be made to rectify the situation as soon as possible. Until that time staff may need to take extra care to safeguard privacy, particularly in sleeping and sanitary areas. In all instance where mixing men and women is unavoidable, the patient, their relatives and carers should be informed of why the situation has occurred, what is being done to address it, who is dealing with it and some indication as to when it may be resolved. All providers will undertake the NHS Institute for Innovation and Improvement checklist and develop and publish an action plan to increase compliance. Progress against the action plan will be monitored through the Quality Board(s). 3. Conclusion 3.1 Action plans have been developed to meet the June 30th target. These plans include future developments to raise the standards even further. A partnership approach has been taken through the Clinical Quality Board. There is some confidence that CHfT will reach the standards set out in the framework but there is significant challenge for MYHT. The MYHT are however, putting considerable effort into this agenda and making significant progress.
4. NHS Kirklees Commissioning Action Plan
Raising the focus
Action
Expectations
Progress to Date
Timescale
The Board demonstrates its commitment to privacy and dignity
Statement of commitment and action plan are published on Trust Web site
Statement on Web site
Completed
Chair of the Board is Champion for EMSA
May 2009
Regular performance reports are presented to the Board
The Board is aware of progress towards 2009 target and any risks to achieving our goal
Reported as part of regular performance report
Ongoing
The contracting Board receives the minutes of the clinical quality board and the chair reports to this group bi monthly
Any variances are acted on. Incentive agreed through clinical quality Safety and quality are part board of the contract monitoring process. Incentives can be agreed as part of CQUINS to drive agenda
Updated action plan available on web site
•
October 2008
to deliver releasing time to care Executive Director chairs clinical quality boards
Metrics and Assurances Action plans
•
The care environment
Patient experience surveys
Ongoing
from all providers are monitored against criteria
is clean and well maintained
completed. HCAI rates reduced. Compliance with Hygiene code
•
There is good separation of sleeping accommodation for men and women
Trusts have single sex bays and single rooms available in all areas except those where clinical care will be compromised. Variances are reported
Plan monitored two weekly for progress towards this target. CHFT Showing two weeks slippage, asked to report how this will be actioned. Updates attached In the case of MYHT there are issues re quality of the estate and meeting the 2009 June deadline is a challenge. Still issues of signage and separation. Updates attached SWYMHT action plan requested through clinical quality board , senior director in SWYMT given responsibility , two weekly reports on progress requested This is been closely monitored by the health economy
Ongoing
•
The physical environment is appropriate for all care groups
Children the elderly and those with mental health conditions are offered appropriate accommodation and the Patient experience is positive.
PROMS and PREMS measures. Will form routine element of contract monitoring through clinical quality board
Next report June 2009
There are segregated toilet and washing facilities for men and women
Good Practice
There are segregated toilet and washing facilities for men and women
Monitored through action plan
June 2009
All breeches are reported through Quality board with action plans for improvement
Escalated to Contract board if any significant issues arise that cannot be resolved through clinical leadership
Ongoing
Leadership
Ownership of this agenda Patient Safety. privacy and dignity and by executive directors from CQUINS are standard agenda items on all three organisations and quality board NHS Kirklees
Innovation
Incentivised releasing time to care in Trusts and community hospital
ONGOING
This will allow leadership at ward level to June 2009 focus on privacy and dignity and Key performance indicators monitored through contract board and clinical quality
board
Raising the focus
Sharing Good Practice
NHS Kirklees , Calderdale AND Wakefield District plus the three Trust are all work across the Health Economy to share good practice
Joint Quality boards and working together of Directors and senior mangers with responsibility for EMSA
ONGOING
Action EMSA CHFT action plan monitored via Clinical Quality board monthly
Lead organisation
Date
Progress
NHS Calderdale; NHS Kirklees
Monthly
Completed
â–Ş Clear designation of toilets & bathrooms at CRH & HRI on all Ward Areas.
CHFT
Nov-08 Completed
▪Improved signage is required to clearly designate the toilets, bath/shower rooms ▪Institute of Innovation & Improvement Good Practice Guidance & Self Assessment Checklist to be undertaken in both Medical Assessment Units & the Surgical Assessment Unit to seek to enhance practice & maximise privacy & dignity. ▪To be completed in all other wards & departments ▪Best practice guidance to be drawn up, disseminated and followed in all urgent care areas in line with findings of self assessment & Dept. of Health guidelines ▪Review of Day case procedure areas to enhance privacy & dignity in these settings (in line with Dept. of Health Guidelines) Challenge Fund bid Implementation
CHFT
Within MSA Privacy & Dignity Temp signage in place business case in for Challenge Fund permanent DDA compliant signage Bid
CHFT
Oct-08 Completed
CHFT
Mar-09 Completed
CHFT
Nov-08 Completed
CHFT
Nov-08 Completed
CHFT
Jun-09
Establishment of Project Task & Finish Board CHFT Paper to be submitted to inform Operating Framework re plans to eliminate Mixed Sex Accommodation (will be submitted to April Quality Board) Planning & Design
Metrics and Assurance
CHFT
20-Mar-09 Established
CHFT CHFT
30-Mar-09 Submitted 10-Apr-09 On schedule Signage will be ordered. Scoping 10-Apr-09 curtain order
Signage & curtains to be ordered Paper & Options Appraisal to Trust Executive Board - CHFT Construction to commence Ward reconfigurations
CHFT CHFT CHFT
Mid May - 30.6
Review of policies to affect practice.
CHFT
1.4.09 - 30.6.09
Develop communications strategies Challenge Fund bid Implementation - monitoring
CHFT NHS Calderdale; NHS Kirklees
1.4.09 - 30.6.10
CHFT 20th April 09
On schedule 11-May-09 2 week slippage
Monthly through CQB - end June 09
Develop Real time patient feedback methods in Assessment areas to assess privacy and dignity to be explored and agreed. To be in place by July 09 Clinical leadership - to include regular matron reviews of clinical areas Breaches reporting and monitoring to be agreed via Clinical Quality board and in place from July 09
CHFT
Jul-09
CHFT
To be confirmed at April CQB
NHS Calderdale
July 2009
Good Practice Good practice guidance to be rolled out across all clinical areas Development of patient information to be given pre admission and on admission Action plan to be developed following self assessment of all clinical areas Chair of PCT's to champion EMSA with Chairs at regular 1:1's CE to champion EMSA with CE's at regular 1:1's
CHFT
Jul-09
NHS Calderdale; NHS Kirklees
Jul-09
CHFT
Apr-09 On schedule
NHS Calderdale
Ongoing
NHS Calderdale
Ongoing
Communication Leads working on regular staff engagement plans including publicising DH policy
NHS Calderdale
Apr-09
Review / Develop local privacy and dignity policies
NHS Calderdale; NHS Kirklees; CHFT
Jun-09
Review NHS organisation public statements on EMSA/ Privacy and Dignity
NHS Calderdale; NHS Kirklees; CHFT
Apr-09
HEALTH ECONOMY Delivery Plan to Eliminate Mixed Sex Accommodation at MYHT to be updated weekly SHA funding available 250K excluding bed management system 1. Raising the focus NHS Wakefield District is committed to raising the focus across the district that Mixed Sex Accommodation matters to patients, impacts on their experience and adversely affects privacy, dignity and confidence. This will be achieved by the following means:
Assessment of Performance 1.1
Improvement Patient experience
Deliverable Review of the 6 month weekly patient experience survey carried out by Chief Nurse and other senior nurse
Update Report completed
Timescale May 09
Funding Stream N/A
Share findings with PCT(s) and Steering Group as best practice
Purchase of patient experience tracker (3 year contract)
Meeting with possible contractor planned (awaiting actual costings)
End May 09
N/A
End June 09
ÂŁ45,000 allocated by SHA
1. Raising the focus NHS Wakefield District is committed to raising the focus across the district that Mixed Sex Accommodation matters to patients, impacts on their experience and adversely affects privacy, dignity and confidence. This will be achieved by the following means:
Assessment of Performance
Improvement
Deliverable
Update
Timescale
Funding Stream
1.2
EMSA policy
Review of current policy
Current policy noted as good practice by SHA at visit in
End June 09
N/A
Database to collect information including breaches
Database in development
End June 09
N/A
End June 09
N/A
April 09
ÂŁ1.8k allocated by SHA spent
Re-launch of policy
SHA requested policy to be shared as good across Yorkshire and Humber
1.3
Enhancing dignity
Purchase of pyjamas
Purchase completed
Pyjama availability focused on area which will create the highest impact particularly exception areas.
2. Metrics and Assurance To enable the monitoring of privacy and dignity the following metrics and assurances will be applied until further national metrics are developed:
Assessment of Performance
2.1
Improvement
Project management
Deliverable
Update
Timescale
Project team in place
Appointed Band 4 admin support/back fill ( 48k)
April 09
Ward visit
All c wards visited
6th May 09
3 Key challenging wards at PGH visited by SHA/PCT Team
Review of accommodation and washing and toilet facilities presented to MYHT Executive Team
Funding Stream
ÂŁ58,000 allocated by SHA (any slippage to be identified and reallocated)
2. Metrics and Assurance To enable the monitoring of privacy and dignity the following metrics and assurances will be applied until further national metrics are developed:
Assessment of Performance 2.2
Improvement Signage
Deliverable Assessment of signage
Update
Timescale End June 09
£5,000 allocated by SHA. Current estimate is likely to be more than allocated by SHA
Permanent signage denoting bed areas, toilet and washing facilities to be purchased and displayed in all identified areas as detailed below DDH Wards 5,6,8,9,10,20,21,ICU,HDU,MAU,CCU PGH Wards 1,2,5,7,E,G,H.P,Q,E,G and P PGI Wards 1a,1b,2a,2b,5,6,,11,12,17,MAU 2.3
Alterations to sleeping accommodation
Total or partial ward areas to be allocated to single gender accommodation as detailed DDH • Paediatric ward to have teenager area developed • Wd 21 Redesign entrance to 4 bed bay
Funding Stream
End June 09 End June 09
PGH • •
• •
End June 09 AAU and SSU – identify single sex bays Wd 7 installation of partitions with sliding doors ( following confirmation of fire safety assessment and infection prevention) Wd Q partition the middle of the ward Wd E,G and P doors to be placed on existing partitions
PGI •
Wd 3- creation of partitions
Undertaking option appraisal with 2 options.
End June 09
£12 000 allocated by SHA. £40-45 000 not included in allocation
2. Metrics and Assurance To enable the monitoring of privacy and dignity the following metrics and assurances will be applied until further national metrics are developed:
Assessment of Performance
Improvement
2.4
Reallocation of wards
2.5
Washing and toilet facilities
Deliverable Identify wards which will require reallocation ensuing that it fit’s with the HDP decant programme. DDH • None identified PGH • Orthopaedics to be single gender D- Male FFemale PGI • None Identified Facilities to be altered or redesigned to accommodate gender specific access as detailed
DDH
Update
Timescale
Funding Stream
End June 09
End June 09
Monies to be identified from SHA allocation, MYHT have indicated support funding of works outside of SHA allocation £12 000 allocated by
• •
SHA.
Wds 5,6,8,9, 10 and MAU to remove non assisted bath and replace with shower Wd 21 shower converted into toilet and wash facilities. Non as sited bath converted to shower
PGH •
£6000 allocated by SHA.
Wd 6 conversion of 2 non assisted bathrooms to wet rooms 1- female 1 – male • Wd E one female toilet to be converted to wet room Wd Q staff room to be converted to a wet room and bathroom at the entrance of the ward to a staffroom.
£3000 allocated by SHA. £20000 allocated by SHA.
PGI
• • •
Wd 1a and 2a re-establish disused shower room and install extractor fan Wd 5 and 6 conversion of non assisted bath to wet room Wd12 convert sink area to female shower and washing area
2. Metrics and Assurance To enable the monitoring of privacy and dignity the following metrics and assurances will be applied until further national metrics are developed:
Assessment of Performance
Improvement
Deliverable
Update
Timescale
Funding Stream
2.6
Ensure value for money in line with hospital development plan
Ward 7, Q at PGH and 3 at PGI identified as key challenges Cardiology – to establish feasibility of re allocating due clinical telemetry issues.
End May 2009
Assessment of value for money
Time line of change of accommodation not compliant in line with HDP
To be agreed with HDP project team
Assessment of decant requirements and impact of EMSA
2.7
Identify and procure Bed management system ensuring any on costs and transferability to the new hospital are identified and planned for
To resubmit bid following discussions with SHA and local trust ( to ensure all costs are identified)
Cost not yet identified
3. Identify develop and spread good practice Work will be undertaken across the district to identify good practice, mechanisms will be developed to ensure the sharing of good practice:
Assessment of Performance
Improvement
Deliverable
Update
Timescale
Funding Stream
3.1
Sharing of good practice
See 1.1 and 1.2
N/A
3.2
Develop metrix to measure reduction in patients effected by mixed sex accommodation
Develop metrix
End May 09
N/A
Measure in bed days i) Pre-improvements ii) Improvement achievable in current accommodation iii) Timeline of EMSA with transfer of wards to new hospitals in PGI and PGH
End June 09 and ongoing
N/A
To be updated at weekly meetings C:\Documents and Settings\sdilks\Local Settings\Temporary Internet Files\OLK1BE\Mixed Sex accommodation Action Plan 2009 v3.doc