Defining our patient safety improvement profile

4.1. The patient safety improvement profile has been defined by the current QI programme along with work being undertaken to manage actions contained in the master Action Plan.

4.2. The Master Action Plan (MAP) is a composite action plan of actions from various sources, including those from PSII (formerly Sis/RCAs), Audits, complaints, Quality Priorities, Internal Assurance Visits to mention but a few. The trust’s MAP has the following improvement themes.

  • Policy/Procedure (Not following policy or procedure, unclear, staff unaware, requires updating, lack of contingency, DOLs/MCA not completed, process not clear, SOPs incomplete, not implemented, SOPs incomplete, contract change, business resilience failure, non-delivery of improvement plan, checklist missing, lack of governance, gap analysis not undertaken, implementation not completed, poor or absent documentation, TOR inaccurate, no escalation, audit not done.
  •  Communication (Interpreters not used, lack of communication between specialist teams, incorrect letter/template used, and outpatient appointment not booked. No reflection/lack of awareness, complaint, posters, newsletter incorrect, booklets incorrect, information not given to staff, poor/incorrect signage, lack of learning, DOC not done, lack of engagement, poor governance, email issues.)
  •   Assessment (Miscalculated score, wrong assessment used, inaccurate assessment, no assessment Undertaken, checks not done, incorrect medication.
  •   Reporting (reporting issue, review issue, audit not completed, poor compliance, lack of monitoring, surveying not done, lack of analysis, feedback issue, action plan issue, medical notes issue, proforma issue, template not created, data integrity issue, lack of monitoring, lack of metrics, identity issue).
  •   Training/Roles & Responsibilities (Role and responsibilities (staff unaware of roles/responsibilities, unclear, abdicating responsibility, requiring review, enhanced care not provided, staffing levels issue, rota issue, recruitment issue, JD issue, vacancies, resources, staff support, team structure).
  •   Equipment (Not available, wrong equipment used, out of date equipment, broken equipment, incorrect storage, PPE, fridge issue, not available, maintenance, replacement not ordered)
  •   Environment (Poor environment, hygiene, cleanliness) 

4.3. CHS has a dedicated Quality Improvement team who support the Quality improvement programme.

4.4. It is important to note that further work is need to align the QI programme with Patient safety improvements. Currently QI projects are driven by individual interests and as a result do not fully align with the improvements required. This remains an area of focus for the trust. The following table outlines the relevant QI projects currently underway (as at March 2025). These projects are at varying degrees of maturity; with some in early stages.

 

Patient safety incident response plan 25/26

Theme

QI Programme

Patient Safety

·         Pressure ulcers.

·         Management of deteriorating patients

·         Application of the Mental Capacity Act

·         Nutrition and Hydration

·         MUST screening tool

·         VTE risk assessment

·         Omitted medication doses

·         Ommitted critical medication doses 

·         Timely access to analgesia for Sickle Cell Patients

·         Patient ownership of their medications

·         Expanding the use of virtual wards

·         Malaria treatment in ED

·         Improving perineal trauma outcomes

·         Reducing preterm admissions

·         Reducing avoidable term admission into NNU

·         Violence and aggression

·         Care for critically ill Maternity patients

·         Waiting times of referral to initial appointment

·         Consent for Transanal Hemorrhoidal Dearterialisation

·         Optimising Maternal Posture to labour pain

·         Screening for Prostate cancer for People with Learning Disability

·         Transition from paper care plan to be digitally

·         Proactive and preventative care for people with long-term conditions

·         Staff engagement following patient safety incidents  

 

Patient Experience

·         Medical SDEC Flow

·         Participation in discussion-making and multidisciplinary meetings about their care

·         Motivation Board

·         Parent Education.

·         Understanding of “what matters to you” conversations among frailty team clinicians

·         Uptake of Screening for Prostate cancer for People with Learning Disability

·         Nursing care plan tailored to ITU patients

·         Patient feedback response rating within community services.

·         Hospital at Night/247 CST

·         Enhancing Access and Equity in Antenatal care

 

Clinical Effectiveness

·         Medical student mock clinical examination in paediatrics

·         Use of stool chart on a gastroenterology ward

·         Documentation

·         Neonatal Educational Digital Platform

·         HbA1C in COPD and Asthma patients

·         Training needs analysis

·         Completion of fluid balance chart.

·         BURST (British Urological Researchers in Surgical Training)

·         ACS NSQIP vs SORT pre-op predictive scoring systems

·         National Early Warning Score Documentation

·         PR on static knee extensor muscle strength through a HHD in COPD patients

·         Orthodontic syllabus for Early Years Dentists at Croydon University Hospital.

Health Efficiency and Value

·         SWL Central Remote Monitoring Hub

·         Maternity & Neonatal Leadership Passport

·         Quality Improvement (QI) projects in Maternity and Neonatal services

·         Pathology samples delivery times in AMU

·         Risk assessment and management

Respiratory Digital Health Access

Audit

·         Referral data audit.

·         Tendable in the community.  

IT/Clinical Systems

·         Systems update.

·         Virtual wards technology.

·         Radar.