THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Eliminating Mixed Sex Accommodation (EMSA) Self Assessment, and Action Plan March 2016 ISSUE ACTION LEAD EXECUTIVE OPERATIONAL LEAD DEADLINE/ REVIEW DATE EXPECTED IMPACT/OUTCOME COMMENTS/ EVIDENCE Patient Experience Patient experience of SSA is regularly monitored and reported as required to Trust Board Data collection undertaken on all inpatient wards (see 2) and reported biannually as agreed with local Commissioners. Continue participation in National Patient surveys. Nursing and Patient Services Director Senior Nurse Practice Development Ongoing To measure patient perception in relation to the delivery of same sex accommodation. To monitor trends and any changes in perception, responding to these in an appropriate manner. Reported in Board Papers September 2015 and March 2016 EMSA Action Plan published on website There is a process to track other mechanisms for determining patient experience of SSA, e.g. through patient complaints/comments, PALs, LinKs Complaints panel will consider Privacy and Dignity issues. PAL’s officers carry out patient perception surveys and these are collated through the Patient Experience and Engagement Team. Nursing and Patient Services Director Head of Patient Experience Ongoing To monitor patient experience, consider issues arising from both formal and informal complaints. To develop an action plan in response to key issues identified. Monthly complaints panel. Report to Board on complaints arising from Privacy & Dignity issues. Reported to Board as (1) above. Issues addressed immediately by PAL’s Officers. Themes and trends reported to the Patient, Carer and Public Involvement group
Information leaflets for patients refer to SSA and are available and used by staff in discussions Develop and maintain up to date ward level information. Nursing and Patient Services Director Matrons Currently under review completion date June 2016 Appropriate and understandable information will be available to patients. Patient information Estates Estate able to support virtual Elimination of Mixed Sex Accommodation DoH Estates survey. Appropriateness of MSA signage and use of accommodation included in Matrons Monthly checklist Nursing and Patient Services Director Senior Nurse Practice Development Estates Manager – operations Completed January 2010 and reviewed post TNH moves in December 2010 EMSA requirements met. Declaration on website. Matrons Monthly checklist via CAT EMSA is assured in planning of any new or refurbished capital development schemes EMSA issues are considered and discussed at the planning stage of refurbishment and new build. Guidance for the process and approval for refurbishment work in development with Minimum standards agreed. Senior Nurse Practice Development Estates manager – operations Head of Estates and facilities Ongoing EMSA requirements will continue to be met Plans for works to be undertaken. Guidance for the process and approval for refurbishment work under review
Systems & Processes Regular assurance to the Board. A system of monitoring all occurrences of mixing, whether clinically justified or not Instances of mixing will be reported as per policy. justified instances of sleeping accommodation breaches will be reported at Board level and via Unify to DoH Nursing and Patient Services Director Senior Nurse Practice Development Ongoing Systems will be in place to assure the Board of compliance with MSSA principles. Instances of mixing will be escalated and investigated Board Reports Monthly returns to DoH EMSA Policy available to staff and Patients, contains clear reporting arrangements. Where there are rare occurrences for reasons, a process exists to investigate reason, take prompt action and take remedial actions as required to prevent future occurrence Reporting will take place through as per policy Root cause analysis (RCA) will be undertaken for any instances of mixing Nursing and Patient Services Director Senior Nurse Practice Development Ongoing Systems will be in place to assure the Board of compliance with EMSA principles. Instances of mixing will be escalated and investigated Board Reports Exception reports to SHA and RCA where required (none in 2012-13, 2014-15 or 2015-16) Relevant Trust policies refer to requirement to EMSA and privacy and dignity Trust policies will make expectations clear in relation to EMSA and privacy and dignity Nursing and Patient Services Director Senior Nurse Practice Development Ongoing Trust policies will support the delivery of SSA. Same Sex Accommodation Policy Privacy and Dignity Policy Transfer of Patients Policy Visitors Policy
The Trust can demonstrate the virtual elimination of MSA in: Wards Assessment Units Patients do not share sleeping accommodation or toilet facilities with members of opposite sex Estate and facilities support the delivery of Same Sex Accommodation. Consideration given to EMSA in any refurbishment & new build Patient perception of MSA in Day facilities is under review Nursing and Patient Services Director Estates manager – operations Head of Estates and facilities Senior Nurse Practice Development Ongoing April 2016 EMSA requirements will continue to be met Estates survey carried out in January and December 2010 Patient perception surveys Staff Culture The Board demonstrates a commitment to on-going delivery of SSA EMSA issues will be reported at Board level. Nursing and Patient Services Director Nursing and Patient Services Director Ongoing A non-executive Director will be identified to support issue of EMSA and privacy and dignity Regular Board reports Non-exec identified. The Trust has articulated its intent to deliver care with privacy and dignity within which delivering same sex accommodation is an integral component The Trust will publicly state its commitment to the delivery of care with privacy and dignity. Nursing and Patient Services Director Nursing and Patient Services Director Ongoing Articulated on Trust website. Action plan for EMSA
The FT believes that delivering SSA should the norm. Mixing will only occur by exception for reasons of clinical justification or patient choice The Trust will clearly articulate its commitment to the delivery of same sex accommodation. Nursing and Patient Services Director Nursing and Patient Services Director Ongoing Mixing will only occur when clinically justified or through patient choice. Patient perception surveys. Board reports. Reports through UNIFY RCA Directorate quarterly reviews If mixing does occur, staff attempt to rectify the situation as soon as possible, whilst safeguarding the individuals dignity and keeping the patient informed about; why the situation occurred and what is being done to address it (with indication of timescales) If an episode of mixing occurs patients and their carers will be kept informed of the situation and how this will be resolved (including timescale) Nursing and Patient Services Director Matrons Ongoing All staff will understand and adhere to EMSA principles and the expectations of the Trust. Patients and their carers will be kept informed in those exceptional instances where mixing does occur. Patient information Reports through UNIFY RCA Directorate quarterly reviews Staff Education programmes Barbara Foggo Practice Development Coordinator March 2016