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

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

Principle

Expectations Outcome Lead Person(s)

Target

Date

Progress to Date

1. The board of directors actively support patient’s privacy & dignity:

Ensure that the board is fully aware of the privacy & dignity agenda

To publish the Trust’s commitment in ensuing privacy & dignity of all its local population and service users

The Quality Strategy sets out the work programme on privacy and Dignity under the work stream of Patient Experience and has been endorsed by the Board of Directors in March 2009 As part of CMFT’s commitment to improving communication with patients and the public our website is continually being developed and the Trust is planning to develop a webpage specifically relating to privacy & dignity, as a means of providing information to patients, visitors and service users

Associate Director of

PatientServices

Lead Nurse,

Privacy & Dignity

Lead Nurse,

Privacy & Dignity

Ongoing

Ongoing

Completed

Quality Campaign launched May 2009

The Trust Eliminating Mixed Sex Accommodation Improvement Plan and progress to date, is available on the Trust’s website for members of the public to access.

CMFT Privacy and Dignity web page signed off and available on the Trusts website from December 2009 for members of the public to access at www.cmft.nhs.uk/trust/privacy-and-dignity

1.1There is clear evidence of commitment by the board of directors to improve privacy and dignity arrangements

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Privacy & Dignity Eliminating Mixed Sex Accommodation Improvement Plan: May 2009

Best Practice

Principle


Target

Date

Progress to Date

1.2The board of directors understands what patients want and endeavours to deliver it

Ensure that the patient experience is paramount and the board is fully aware of what patients want by analysing the information gathered from patient experience surveys, complaints and incident reports

The trust is currently implementing the use of the Dr Foster Intelligence's Patient Experience Tracker (PET) an electronic patient feedback system to enable patients to feedback their experience. Patients will be asked questions pertaining to privacy and dignity weekly for a period of one month every 6 months.

The board of directors will commence a series of leadership walks from July 2009 to gain direct patient and staff feedback and directly observe aspects of the patients’ experience which include privacy and dignity.


Patient Services


Patient Services

Completed

Ongoing

Implementation of the Dr Foster PET data collection system for patient experience completed for all in patient clinical areas.

Patient feedback on privacy and dignity questions to be one of series of monthly themes in relation to patient experience collected via newly implemented PET tool. Privacy and Dignity feedback to be collected every 6 months as part of rolling programme. Initial data collection undertaken in July/August 2009. Next data 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.

Initial phase of Leadership walks commenced in June 2009, with a plan to undertake walks in 60 clinical areas across the Trust during the first year of implementation.

Version 7 – December 2009 2/12


Best Practice

Principle


Target

Date

Progress to Date

1.3The board understands the trust’s performance against privacy and dignity benchmarks and sets local goals for improvement

In line with the Trust’ Quality Campaign to agree objectives for improvement, that have been identified through local and national benchmarking

Establish a board reporting framework to enable feedback to the board on privacy and dignity to take place

Monitoring feedback in terms of privacy and dignity from the Dr Foster Intelligence's patient experience tracker (PET)

Monthly analysis and monitoring of information gathered from the Matron/Ward Manager ward round framework.

Quarterly reports to the Board on privacy and dignity

Development of the leadership walks


Patient Services /

Lead Nurse,

Privacy & Dignity

Lead Nurse,

Privacy & Dignity

Director of Nursing (adults)


Patient

From June 2009

onwards

OngoingMonitorMonthly

Jan/Feb2010

Dec2009

Patient feedback on privacy and dignity questions to be one of series of monthly themes in relation to patient experience collected via newly implemented PET tool. Privacy and Dignity feedback to be collected every 6 months as part of rolling programme. Initial data collection undertaken in July/August 2009. Next data 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.

Data collated via Ward Managers and Matrons ward rounds reviewed at monthly privacy and dignity meetings and appropriate actions identified.

Board reports received June and August 2009..

First phase of leadership walks commenced and will continue on a rolling programme. Review of this process



Best Practice

Principle


Target

Date

Progress to 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.

1.4Resources are allocated to preserving and improving the privacy and dignity of all patients and service users

To allocate and monitor use of resources identified to ensure the privacy & dignity of all patients and service users

To ensure that clinical providers have undertaken a self assessment of

A building and refurbishment programme is underway for the older hospital buildings concentrating this year on:

• Medical Assessment Unit (MAU)• Emergency Surgical Unit (ESU)

A rolling programme of improvement works is planned with PFI partners as part of the life cycle works

Director of Nursing (adults)

/ Associate Director of Estates & Facilities/Head of Nursing


Estates and facilities/

Ongoing

Completed

Privacy & Dignity - Eliminating mixed sex accommodation (PDEMSA) meetings held monthly to review progress and establish actions.

Capital refurbishment programme in progress: • Medical Assessment Unit refurbishment completed and opened 26th November 2009.• Endoscopy unit has moved to same-sex lists from November 2009.

Surgical Division reconfiguration - scheduled refurbishments works extended to incorporate life cycle work such as replacement of ceiling, floors and



Best Practice

Principle


Target

Date

Progress to Date

their current position in relation to mixed sex accommodation and produced an improvement plan as part of their plans indicated by the SHA

for the hospitals

The New Hospitals are fully compliant with the guidance on mixed sex accommodation

Head of Nursing


Estates and Facilities

March 2010

August 2010

Complete

redecoration of these clinical areas.• Emergency Surgical Unit to complete March 2010 – becoming same-sex wards, located on Ward 1 and Ward 2.• Renal transplant & Urology refurbishment scheduled to complete August 2010 - becoming same-sex wards, located on Ward 9 and Ward 10.

2 The physical environment actively supports patients’ privacy & dignity

To monitor the Trusts performance in relation to cleanliness and infection prevention and control

To respond to staff, patients and the public when the environment of care falls below acceptable

The development and implementation of the Matron/Ward Manager ward round framework in January 2009, ensures that patients’ experience and patients’ environment are evaluated and is critical to continually improving our performance.

Ward rounds are undertaken weekly, with specific focus on the environment on a fortnightly basis. The results and actions to address any identified issues are collated


Patient Services/Corporate

Lead Nurse

Lead Nurse,

Privacy & Dignity

Ongoing

Ongoing

Ward Manager/Matrons ward round framework captures standards in relation to cleanliness and infection prevention and control. Review of Matron/Ward Manager Ward Round framework undertaken in August and revised elements included in relation of essence of care, patient safety, and valuing patients. Process to monitor and review improvements being established for implementation from January 2010.

Department of Health, Privacy and Dignity Environmental Audit undertaken June 2009 which identified three areas as non-compliant in relation to the environment of care:

2.1The care environment is clean and well maintained



Best Practice

Principle


Target

Date

Progress to Date

standards and demonstrate continuous improvement

electronically

The cleaning and maintenance of the estate is the responsibility of our subcontractors Sodexo Healthcare and Sodexo FM and is monitored by the Trust monitoring team


Estates and Facilities

Complete

Ongoing

• Clinical Decisions Unit (CLDU)• Programmed Investigations Unit (PIU)• Discharge LoungeOngoing 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 implemented.

2.2 There is good physical separation of sleeping accommodation for men and women

To repeat a Trust wide audit using the Institute for Innovation and Improvement Self Assessment Checklist, designed to measure practice against eliminating mixed sex accommodation.

To scope issues relating to mixed sex accommodation.

Analyse and present the findings and oversee individual action plans

Lead Nurse,

Privacy & Dignity

Lead Nurse,

Privacy & Dignity / Heads of Nursing/ Assistant

Director of Nursing

Completed

Complete

Jan 2010

The Institute for Innovation and Improvement Self Assessment Checklist Audit completed in August 2009 for all areas providing patient care.

Results from the self assessment audit collated electronically. Preliminary results circulated to the Heads of Nursing and Assistant Directors of Nursing for appropriate actions as required in October/November 2009.

Action plans to be developed by 14th

December 2009, reviewed and monitored



Best Practice

Principle


Target

Date

Progress to Date

DoH principles for delivering same sex accommodation (Sept 09) state that on mixed-sex wards bay areas should be clearly designated as male or female accommodation.

Agree Trust wide standard for signage to bay/ward areas.

Lead Nurse,

Privacy and Dignity

Jan 2010

by Privacy and Dignity Eliminating Mixed Sex Accommodation meeting

Signage design developed and currently under consultation.

2.3 The physical environment is appropriate for the care group

To repeat the Trust wide scoping exercise in relation to types of accommodation that are used for particular care groups and the appropriateness

Present findings of the scoping exercise and oversee individual action plans, ensuring that all patients are cared for in the most appropriate setting for their need, giving due consideration of their privacy & dignity

Lead Nurse,

Privacy & Dignity

Completed

Completed

Completed

Areas for improvement identified and from privacy & dignity environmental audit undertaken in June 2009.

Patient information leaflet: Same-sex accommodation – ‘we’re making improvements so you’ll feel more comfortable’ developed. Distributed within Trust via Heads of Nursing/Lead Nurses. Available on the Trusts internet for access by the public and service users

‘Pathway specific’ patient information leaflets now developed for: Emergency surgery pathway Elective surgery pathway Critical Care – Intensive Treatment Unit (ITU) and High Dependency Unit



Best Practice

Principle


Target

Date

Progress to 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 segregated toilet and washing facilities

To ensure designation of single sex toilets and washing facilities in clinical areas

Where wards have mixed gender patients being cared for in different bays within a ward footprint, ensure that the allocation and signage by gender is in place for toilet and washing facilitiesMonitor as part of the Matron/Ward Manager ward rounds

Heads of Nursing

&Lead

Nurse, Privacy &

Dignity

Complete

Jan 2010

Results from the self assessment audit collated electronically. Preliminary results circulated to the Heads of Nursing and Assistant Directors of Nursing for appropriate actions as required in October/November 2009.

Action plans to be developed by 14th

December 2009, reviewed and monitored by Privacy and Dignity Eliminating Mixed Sex Accommodation meeting

3. Individual staff actions actively support privacy & dignity

To ensure that the Trust has the appropriate policies and procedures in place and embedded to ensure that the privacy & dignity of patients is considered and maintained

CMFT is currently reviewing and revising the privacy & dignity policy in line with national policy for delivering same sex accommodation (DSSA)

Once this policy has been ratified it will be available on the Trust’s website to enable service users to view

Lead Nurse,

Privacy & Dignity

Lead Nurse,

Privacy and Dignity

Complete

Complete

CMFT has a ratified policy: ‘Provision of Same Sex Accommodation’ which incorporates national guidance for delivering same sex accommodation (DSSA).

Implementation of policy will take place in September / October 2009 as follows:• Widely circulated throughout the Trust• Presented at Ward Manager/Lead Nurse Forum – Oct 2009

3.1 Staff are aware of and abide by policies established to ensure privacy & dignity



Best Practice

Principle


Target

Date

Progress to Date

Bedside curtains redesigned to include “Stop – Do Not Enter” signs integral to the fabric.

Curtains for the new hospital build will include this design, as will all new curtains ordered for wards and departments.

Privacy and dignity issues go beyond the elimination of mixed sex accommodation and the policy and action plans will recognise this and set out plans for improvement including, information for patients, attitude and behaviour

Heads of Nursing

Lead Nurse,

Privacy and Dignity

Lead Nurse,

Privacy & DignityQuality

Campaign Manager / Head of Nursing - Medicine

Ongoing

Ongoing

Completed

Completed

• 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

Completed implementation within adult Surgical in patient areas. This design of curtains has been implemented in the new hospital development.

NHSII audit feedback will identify areas for new curtains during next phase.Work ongoing to develop a specific privacy, dignity and respect policy which will be launched in December 2009.

As part of the Trusts ‘Quality Strategy’, CMFT is working in partnership with the Royal college of Nursing (RCN) to promote and embed their ‘Dignity’ Campaign’ – Delivering Dignified Care and identifying ‘dignity champions’ 53 staff members of staff have been trained as ‘dignity champions’.

As part of the Quality campaign – ‘Brilliant Basics’ the Privacy Dignity and Respect



Best Practice

Principle


Target

Date

Progress to 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 all episodes of mixing, and keep patients and

visitors informed about actions that are being taken to solve the problem

To ensure that the appropriate policies and procedures in place and embedded to ensure that the privacy & dignity of patients is considered and maintained.

Any occurrence of mixing is reported through the electronic incident reporting system and investigated.

CMFT is to devise patient information leaflets for both planned/elective care pathways and unplanned/emergency care pathways. These leaflets will fully inform patients and visitors of the provisions of their care environment, giving due consideration of their privacy & dignity

Analysis and monitoring of incidents data relating to mixed sex accommodation

Lead Nurse,

Privacy & Dignity

Lead Nurse,

Privacy & Dignity

Lead Nurse,

Privacy and Dignity

Complete

Ongoing

Ongoing

Completed

CMFT has a ratified policy: ‘Provision of Same Sex Accommodation’ which incorporates national guidance for delivering same sex accommodation (DSSA). The policy includes clear escalation processes and actions staff are required to take should incidence of non compliance occur. Any incidents are investigated in line with the Trust Risk Management Policy.

Weekly report from incident reporting system established to Lead Nurse for Privacy & Dignity and Assistant Director of Nursing (Adults) to provide monitoring mechanism for policy standards.

Ward managers and matrons ward round 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.

Working with Communications Team to develop article for the Trust’s magazine ‘Insight’ to increase staff awareness of



Best Practice

Principle


Target

Date

Progress to Date

Completed

Jan 2010

policy and Trust improvement plan.

Article planned for ‘Quality Matters’ trust quality newsletter and web update via the Quality web site to take place December 2009.Article planned in January patient safety and risk management newsletter ‘Lesson Learnt’.

3.3 Staff report episodes of

mixing through the appropriate channels

To ensure that the appropriate policies and procedures in place and embedded to ensure that the privacy & dignity of patients is considered and maintained.Any occurrence of mixing is reported through the electronic incident reporting system and investigated

Analysis and monitoring of incidents data relating to mixed sex accommodation

Lead Nurse,

Privacy & Dignity

OngoingMonitoring

OngoingMonitoring

OngoingMonitoring

CMFT has a ratified policy: ‘Provision of Same Sex Accommodation’ which incorporates national guidance for delivering same sex accommodation (DSSA). The policy includes clear escalation processes and actions staff are required to take should incidence of non compliance occur. Any incidents are investigated in line with the Trust Risk Management Policy

Weekly report from incident reporting system established to Lead Nurse for Privacy & Dignity and Assistant Director of Nursing (Adults) to provide monitoring mechanism for policy standards.

Ward managers and matrons ward round 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



Best Practice

Principle


Target

Date

Progress to Date

Complaints and PALS information analysed monthly

Matrons/Ward Manager ward rounds to access patients views

Feedback from the patient experience tracker (PET) in relation to privacy and dignity to be analysised and actions agreed where issues have been identified.

Board of directors receive information through the intelligent board reports – patient experience indicators

Associate Director –

Patient Services

Lead Nurse Privacy &

Dignity


Patient Services

Director of Informatics & Associate Director of

Patient Services

Ongoing

Ongoing

Jan2010

Reporting framework under development in order to report patient experience indicators for nursing, such as privacy and dignity on regular basis to the Board. Patient experience metrics for intelligent board agreed currently developing format for presentation with Trust.


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

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