4. 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  • Equipment (Not available, wrong equipment used, out of date equipment, broken equipment, incorrect storage, PPE, fridge issue, not available, maintenance, replacement not ordered)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 2023). These projects are at varying degrees of maturity; with some in early stages.


QI Programme 2023/2025


QI Programme


  • Voice recognition dictation roll out.
  • Outsourced transcription services.


Staff Experience

  • Junior doctors experience on rotation.
  • Professional Nurse Advocate awareness.
  • Restorative Just Culture.
  • QI engagement.
  • Reducing stress.
  • Improved culture in organisation.

Patient Safety

  • Pressure ulcers.
  • Core temperature management in neonates.
  • Pharmacy discharge interviews.
  • Intraoperative observations labelling.
  • Improve lying and standing blood pressure documentation.
  • QSIR training.


  • Duty of Candour.
  • New NICE guideline-Sickle Cell disease.


  • ODP training.

Record Keeping

  • Community nursing.
  • Agency Nursing.
  • MCCD Form completion.

Patient Experience/ Information

  • Surgical pathways leaflets.
  • SDEC leaflet.
  • Healthcare passport.
  • ICN+ MDT effectiveness.
  • ACT informed intervention.
  • Patient level costs to aid decision-making.


  • Cancer care in ED.
  • Bowel screening for LD patients.


  • Older people LOS.
  • Virtual wards.
  • Discharge process.
  • Criteria-led discharge.
  • Orthopaedic inpatient LOS.
  • Implement integrated discharge team.



  • Detection of anaemia pre-op.
  • Post op hypertension.
  • Clinical handover.
  • Bone Health.
  • HPV uptake in yr.8.
  • Medical ward task completion.
  • Prevent avoidable DVT.
  • Improved detection of deteriorating patient

Clinical Pathways

  • Scaphoid fracture management.
  • Eye referrals to Moorfields.
  • Vertebral fracture management.
  • Abdominal surgery in frail patients.
  • Reducing inappropriate referrals to SDEC.
  • Delayed cord clamping in maternity.



  • Diagnostics requests.
  • Label management.



  • Referral data audit.
  • Tendable in the community.


IT/Clinical Systems

  • Systems update.
  • Virtual wards technology.
  • Radar.