wrightington, wigan and leigh nhs trust · wrightington wigan and leigh nhs trust ... ma t io n to...

Wrightington Wigan and Leigh NHS Trust Quarterly Risk Management Report January to March 2007

Wrightington, Wigan and Leigh NHS Trust

Risk Management Report

January to March 2007

Compiled by: Pam Powell, Head of Governance with inputs from:- Helen Hand, Patient and Public Involvement Co-ordinator Lesley Boyd, Complaints Service Manager Connie Gorman, Medicine Safety Pharmacist Christine Birchall, Acting Patient Safety Manager John Buck, Health and Safety Manager Michelle Cloney, Assistant Director of Organisational Development and Lifelong Learning Stephen Clancy, Senior Fire Adviser

1


CONTENTS

Page No

1. Patient Advice and Liaison Service 3

2. Complaints 6

3. Patient and Staff Safety 12

4. Fire Safety 21

5. Training and Development 24

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1. THE PATIENT ADVICE & LIAISON SERVICE (PALS)

The Patient Advice and Liaison Service has had another busy period between January and March 2007. A total of 428 contacts were received from patients, the public, carers or members of staff.

The highest levels of activity during the quarter fell under the categories of Access to services, Delays in treatment and in providing Information. Below are some examples:

Access

A number of patients contacted the PALS department who are still having problems accessing the appointments lines at Leigh and Wigan.

Outcome: PALS contacted relevant manager who is investigating the problems and looking at putting a answerphone in place as an interim measure so patients can leave a message. Other solutions are being looked at.

Delays

A patient received a letter in October 2006 to say that he had been referred to the arthroplasty service and would receive further correspondence. Patient has still not received anything February 2007.

Outcome: PALS contacted the General Manager and the Arthroplasty nurses. They were informed that the Arthroplasty nurses were currently triaging the patients to put into the relevant clinics. The Arthroplasty outpatient clinics were scheduled to begin from March 13th. The patient was informed an appointment would be sent out to them after this point. A patient arrived for his outpatient appointment in the Ophthalmology Department but could not be seen by the Consultant. PALS contacted the department to investigate why the Consultant could not see the patient. It was reported that the patient had failed to attend for his field test appointment and therefore the Consultant had no reason to see him, because he had no results to give to the patient. A new double appointment was given to the patient for his field test and his consultation. The patient was informed, who insisted he had not received the first field test appointment Information A patient who was due to go on holiday 4 weeks after having a laparoscopy wanted to know if she was okay to fly. PALS informed the patient that she should not fly for up to 6 weeks after having a operation. Patient therefore cancelled the date of the operation and was given another appointment. A patient who had been listed to have an operation on his tennis elbow had been informed by his GP that he could lose up to 50% of movement in his arm. The patient was requesting more information on risks of the procedure.

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Outcome: PALS contacted the appropriate surgeon and it was advised to arrange for the patient to attend the outpatient clinic to discuss the procedure.

A patient requested clarification of the level of qualification of a doctor who had performed their operation two years ago; the patient had been given to understand a GP had performed the surgery. Outcome: PALS contacted Medical HR to check the information. PALS confirmed with the patient that the doctor who performed the surgery was a Specialist Registrar

Actions and Controls Implemented Leigh Out Patients department now record the patient arrival time on the patient record to ensure patients are seen in the correct time slots. This was implemented following patients reporting that they were not being seen in the correct order. Training One to one training sessions with social worker students and student nurses continue to take place. A training session for the new senior house officers in the A&E department is currently being followed up with the department Evaluation And Feedback The PALS service received 7 compliments from members of the public thanking hospital staff for the care they received whilst in hospital. There has been a steady increase in the number of patients/public/carers and staff calling in person to the department. Statistics A total of 30 cases (7%) were referred on to the Formal Complaints Department. An increase of 1% on the previous quarter.

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PALS Top four areas of activity

25

15

33

9

68 67

128

102

80

62

45 43

60

4842

54

110

118

92

84

123

108

89

109

29 31

78

26

78

49

8488

0

20

40

60

80

100

120

140

Q1 04/05 Q2 04/05 Q3 04/05 Q4 04/05 Q1 05/06 Q2 05/06 Q3 05/06 Q4 05/06

Access to service Clinical care Delays reported Information

5


2. COMPLAINTS SERVICE 2.1 Learning from complaints

The Trust welcomes the views of people who have experience of our services, even if they are critical. Complaints are viewed as an opportunity to view the services the Trust provides through the eyes of the people using them, in order to learn from their experiences and improve services for the benefit of others who may use our services in the future. The Complaints Service meets regularly with Divisional teams to follow up on actions taken in the light of complaints to improve services and provides regular reports and summaries to the Divisions to identify trends and particular areas of concern. Action plans for changes in the light of complaints are monitored to ensure that we extract lessons from complaints. Much of the learning that takes place is in relation to staff reflecting on their actions and seeing things from the patients’ or relatives’ perspective. However below are a few examples from each Division where it was highlighted that making changes and learning from complaints could benefit the service user.

Medicine

At the Thomas Linacre Centre a hot drinks machine has been ordered for this

area used by the oncology clinic for the comfort of those waiting in the clinic. A range of actions around the organisation of care and nursing practices on

Shevington ward is being undertaken and a senior nurse has been tasked with undertaking practice development work with the ward staff

Updated transfer form for patient discharges has been implemented

The need to check that cannula is removed prior to discharge has been added to

the discharge policy.

Surgery Following discussions prompted by a complaint a joint decision was made between the ENT Consultants and the Anaesthetic Department that there was no particular need to stop oral contraceptives prior to tonsillectomy and this is now policy. ENT team will proceed with Tonsillectomies as planned under these new guidelines. On Swinley ward the ward manager has introduced monitoring procedures to

ensure that discharge medication is checked with each patient as they are discharged. In addition this matter is being followed up by the medicines safety pharmacist who will report on any further changes or improvements, which may be appropriate

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Musculoskeletal

Arrangements made for issues relating to consent forms to be brought to the attention of the medical staff within the training module on documentation and record keeping.

Matron is arranging for nursing staff to update their knowledge and skills in

relation to the care of rheumatology patients.

The Musculoskeletal Division is currently reviewing admission arrangements. 2.2 Statistics

The trust received 137 complaints this quarter compared with 106 in the previous quarter and 118 in the same quarter in 2006. The cumulative number of complaints received from 1 April 2006 to 31 March 2007 is 457, compared with 432 for the previous year.

Complaints for this quarter by subject are as follows:

11

3

17

0 0 0

17

55

17

0 0 0 1 0 0 04

1 0 0 1 14 4

10

10

20

30

40

50

60

Admission, discharge and transf..

Aids and appliances, equipment,...

Appointments, delay/cancellation...

Appointments, delay/cancellation...

Length of time for response NHS...

Length of time to se seen Walk i...

Attitude of staff

All aspects of clinical treatment

Communication/information to pa...

Consent to treatment

Complaints handling

Patients' privacy and dignity

Patients' property and expenses

HA PCG commissioning

Independent sector services pur...

Independent sector services pur...

Personal records (including medic..

Failure to follow agreed procedure

Patients' status, discrimination e...

Mortuary and post mortem arra...

Transport (ambulance and other)

Policy and commercial decisions...

Code of openness complaints

Hotel services (including food)

Other

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Complaints by subject compared with same quarter last year:

72

27

40 0

10

45

12

0 0 0 0 0 0 0 3 1 0 0 1 0 0 2 411

3

17

0 0 0

17

55

17

0 0 0 1 0 0 04 1 0 0 1 1 4 4 1

0

10

20

30

40

50

60

Admission, discharge and transfer arr...

Aids and appliances, equipment, prem...

Appointments, delay/cancellation (outp...

Appointments, delay/cancellation (in-pa...

Length of time for response NHS Direct

Length of time to se seen Walk in Cen...

Attitude of staff

All aspects of clinical treatment

Communication/information to patient (...

Consent to treatment

Complaints handling

Patients' privacy and dignity

Patients' property and expenses

HA PCG commissioning

Independent sector services purchase...

Independent sector services purchase...

Personal records (including medical a...

Failure to follow agreed procedure

Patients' status, discrimination e.g. racia..

Mortuary and post mortem arrangements

Transport (ambulance and other)

Policy and commercial decisions of Tr...

Code of openness complaints

Hotel services (including food)

Other

05/06 06/07

This quarter has seen a reduction in complaints about delayed and cancelled outpatient appointments, compared with the same quarter last year and is indicative of a downward trend over the last two years. However there has been an increase in complaints about staff attitude. This is being followed up within the Complaints Performance meetings and the division’s governance arrangements.

The increase in complaints about staff attitude reflects a general increase over the last two years. Complaints about all aspects of clinical treatment saw a significant increase this quarter in contrast with a downward trend for the remaining top five subject areas of complaint as the chart below shows.

0

10

20

30

40

50

60

05/ 06 Q1 05/ 06 Q2 05/ 06 Q3 05/ 06 Q4 06/ 07 Q1 06/ 07 Q2 06/ 07 Q3 06/ 07Q4

Admission, discharge and t ransf er arrangement s Appoint ment s, delay/ cancellat ion (out pat ient )

At t it ude of st af f All aspect s of clinical t reat ment

Communicat ion/ inf ormat ion t o pat ient (wr it t en and oral)

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2.3 Performance

The national performance standards as set out in the NHS Complaints Procedure are as follows:

1 acknowledgement within two days of receipt or full response within five days 2 full response within 25 working days 3 response in excess of 25 days with complainant’s consent

The Trust is required to report performance against these targets to the Department of Health on an annual basis

The standards were met during this quarter as follows:

Standard Total Percentage

1 137 100 2 123 90 3 14 10

This was an extremely busy quarter and the standard was not met in 14 cases due to the complexity of the cases concerned, involving more than one area, which meant that information was not received from the Divisions before the deadline.

Cumulative performance up to end of March 2007 is 90% of complaints received a response within the 25 day target.

Divisional Performance:

Division / Directorate

Number of Complaints

Responses on target

Performance for quarter

Cumulative Performance

Clinical Support 17 15 88 97 Estates and facilities

5 5 100 100

Medicine 65 56 86 87 Musculoskeletal 22 21 95 93 Surgery 28 26 93 86

The Complaints Service continues to seek improvements through regular contact with key personnel within the divisions, and systems to highlight potential breaches.

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2.4 Healthcare Commission

In this period the Trust was made aware of 1 referral to the Healthcare Commission, although this does not relate to a complaint received this quarter.

This quarter the Trust received feedback on 6 complaints in this quarter. 4 relate to complaints received in 2005 and 2 to complaints received in 2006. These are summarised below:

Complaint Actions / recommendations Ref: 1220 Attitude of doctor and treatment in ECC

Main recommendations: The doctor reflect on this The trust ensure that there are policies and

procedures in place for management of urethral catheters within ECC

Whilst both recommendations were taken forward within the ECC, the patient has logged a claim for compensation and the file has been closed.

Ref: 1146 Complaint concerning cancelled outpatient appointments and a lack of diagnosis of skin problem following mastectomy

The complaints about clinical aspects were not upheld Main recommendations: The trust should review policies and procedures in

relation to communications with patients and booking appointments within breast unit The Trust should apologise for poor administration

of appointments Complainant has been advised of the changes and additional medical staff since her complaint in 2005. Patient has returned to the care of WWL. The Trust apologised for the difficulties experienced with appointments in the past.

Ref: 1151 Complaint concerning inadequate pain relief during admission; patient required tests but these were not carried out; discharge arrangements; staff discriminated against patient as he had made a complaint

Main recommendations: The trust should confirm what tests were ordered

and if they were cancelled explain why. The trust should ensure that patients’ next of kin are

informed when patients are discharged The Trust should confirm what follow-up

arrangements should be made for patients who are discharged with anaemia Staff should be reminded that negative comments in

relation to a complaint may impact on perceptions of care

These recommendations are being taken forward.

Ref: 1306 Alleged failure to offer surgery for cancer: delay in referral for chemotherapy

Complaint in relation to failure to offer surgery was not upheld. Recommendation: The Trust apologise for the (slight) delay in referral

for chemotherapy (although this would not have changed the outcome

The Trust has considered the recommendation and offered apologies.

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Complaint Actions / recommendations Ref 1358 Treatment of cancer

Complaints in respect of treatment of cancer were not upheld Other recommendations: The Trust implements a policy to support patients

with learning difficulties The Trust implement changes in relation to

education and care in respect of end of life care The Trust has made an initial response to complainant and is taking recommendations forward.

Ref: 1395 Discharge arrangements

Main recommendations:

The Trust should review discharge policy and ensure that responsibility is placed with consultant lead The trust should review complaint again in line with

clinical practice standards (given patient’s readmission and need for blood transfusion) Medical Director to review case in relation to

medical team involved That the trust make adequate arrangements for

discharge planning That the staff are aware of how to offer assistance

to those who wish to make a complaint This complaint has been reviewed by the Medical Director and recommendations have been taken forward with the division.

5 Training

The Complaints Service has provided training at 5 Mandatory training sessions this quarter. In addition the service has been able to secure a session within the Induction training day for new staff. Training for new staff commenced in January 2007.

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3. PATIENT AND STAFF SAFETY TEAM 3.1 Clinical Incidents

Incidents reported in quarter 4 were compared by category to the incidents reported in the previous 3 quarters. The top 5 incidents reported remain consistent, in relation to both category and numbers.

The top 5 categories make up 83% of the total incidents reported

Top 5 Clinical Incidents

0

50

100

150

200

250

300

350

Q1 06/07 Q2 06/07 Q3 06/07 Q4 06/07

Quarter

Num

ber

Found on Floor

Direct Care

Slip, trip and falls

Medicine Safety

Communication,Confidentiality andConsent

Found on Floor remains the highest reported incident with 31% (321) in quarter 4. Slip/trip or falls takes up approximately 40% of the incidents reported to PSST in both the 1st and 3rd quarter, but only 30% were responsible for the total incidents reported in the 2nd quarter and 13% in the final quarter.

The Surgical Division reported 47% of incidents in direct care, the Medical Division 35% and Musculo-skeletal 11%.

The top 3 most frequently used sub-categories from Direct Care are.

• Cancelled or delayed surgery/treatment/procedure (14%) • Inappropriate admission/transfer (14%) • Minor injury sustained (14%)

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Direct Care Incidents

0

10

20

30

40

50

60

Q1 06/07 Q2 06/07 Q3 06/07 Q4 06/07

Quarter

Num

ber

Minor Injury

Cancelled/Delayed

InappropriateAdmision/Transfer

There is a continued reduction in cancelled or delayed surgery/treatment/procedure and the incidence has more than halved since the first quarter.

Reported Clinical Incidents

The department received a total of 1026 Patient Safety Incidents during the quarter 4 period. This showed 334 incidents as near misses and 692 as adverse events

Internal Patient Safety Notice (IPSN)

At the time of this report there are three current Internal Patient Safety Notices, which are at Stage 4.

IPSN 001, was issued regarding ‘Last Offices’ As a result of this IPSN, Guidelines have been written and distributed to all Divisional leads including Heads of Nursing and Clinical Directors for their comments. All staff have been informed regarding the ‘Last Offices’ process, and this has resulted in a 43% reduction in errors made in the month of March. In order to prevent, further errors occurring it has been agreed between the mortuary and the PSST that the mortuary will provide a monthly report and the PSST will ensure that this is fed back through the divisional risk management meetings. An additional recommendation has been made that a steering group is established to develop a Policy and Procedure for Last offices.

IPSN 004, Naso-gastric tube insertion, was issued as a result of a ‘National alert’ from the NPSA regarding a number of reported deaths and near misses. Although there have been no reported incidents within Wrightington, Wigan and Leigh NHS Trust it was felt that the serious nature of the alert required action, to ensure that the potential risks and additional recommendations were brought to the attention of all staff who are or are potentially involved with the insertion of NGT insertion.

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There have been no reported incidents involving the insertion of naso-gastric tubes within this Trust. An up to date policy and procedure is available to all Trust staff on the Intranet and also, following this alert, should be stored within the Policy file. The Nutrition Nurse Specialist provides training to staff

IPSN 003, Intravenous Fluids, was issued following a report by the NPSA, which indicated a national problem in the prescribing of IV fluids. A Steering Group is to be appointed which will be responsible for the development of a Policy, Procedure and Guidelines on Intra-venous fluids

All the IPSN reports are scheduled for presentation at the next Clinical Governance and Standards Board.

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3.2 MEDICINE SAFETY

A total of 197 reports were received during this quarter, this is a 57% increase on the same period last year however a 16% decrease on the previous quarter. A total of 729 medicines related incidents were reported this year; this is just below the NPSA estimate of 1 medicines related incident per bed per year.

Medicine Safety Incidents

0

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05/0

6 Q

1

05/0

6 Q

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6 Q

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05/0

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06/0

7 Q

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06/0

7 Q

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06/0

7 Q

4Quarter

Num

ber o

f inc

iden

ts

Of the 196 medication incident reports received this quarter 101 (51%) were reported via the Mediform system, i.e. these reports originated from the pharmacy department.

The rise in the use of the mediform as highlighted in the graph overleaf is a direct result of a change in pharmacy department procedure whereby all dispensing errors within the department are reported using this scheme. The ward pharmacists have also been encouraged to use the forms when carrying out clinical duties on the ward. This would also partially explain the slight decrease in use of the Trust Incident Reporting forms.

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Reporting scheme used

0

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160

05/06

Q1

05/06

Q2

05/06

Q3

05/06

Q4

06/07

Q1

06/07

Q2

06/07

Q3

06/07

Q4

Quarter

Num

ber o

f inc

iden

ts

MediformIR 1 Form

The number of near miss incidents reported this quarter remains steady at around 25% of reported medicines related incidents, this is comparable with previous quarters and further work must be done to increase the reporting of near miss medication incidents. The need to report near miss incidents is highlighted in both mandatory and induction training for clinical staff.

Outcome of Medication Incidents

0

20

40

60

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120

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160

180

05/06

Q1

05/06

Q2

05/06

Q3

05/06

Q4

06/07

Q1

06/07

Q2

06/07

Q3

06/07

Q4

Quarter

Num

ber o

f Inc

iden

ts

AdverseEvent

Near Miss

SeriousAdverseEvent

There has been no serious adverse events’ relating to medicines use reported this quarter.

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Medicine Safety Category

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80

05/06

Q1

05/06

Q2

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06/07

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Q4

Quarter

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ber o

f inc

iden

ts AdminAdviceDispenseGeneralMonitoringPrescribing

The above graph demonstrates a reduction in dispensing and administration errors and an increase in the reporting of prescribing errors. Following the dramatic increase in dispensing errors during the last quarter the pharmacy department implemented a change to dispensing procedure, which has resulted in a 20% reduction in errors since the last quarter.

At pharmacy clinical team meetings during January, all pharmacists were encouraged to report medication incidents discovered whilst carrying out clinical duties on the wards. They were each issued with a Mediform pad and reminded on the appropriate use of the forms via an email and pharmacy newsletter. This may explain the increase in the reporting of prescribing errors.

54% of reported incidents were graded as very low, 36% graded as low and 10% graded as moderate harm. The incidents graded as moderate harm included: • Patient transferred to Whelley without medication or prescription chart, therefore

nursing staff unable to administer medications • Warfarin patient discharged from ward without discharge prescription. Given last

dose on the ward and informed to return to collect prescription the following day. INR unstable whilst inpatient, No INR test taken on day of discharge, no warfarin prescribed on discharge and no anticoagulant clinic appointment arranged. Patient attended ward for INR and all monitoring arrangements made before discharge medication released from pharmacy.

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• Patient attended PIU for INR check, was on aspirin, clopidogrel and warfarin. This combination of anteplatelets is not recommended. Sister on PIU noted error and discussed with Dr, one agent discontinued.

• Patient documented as allergic to penicillin on drug board and red wristband in situ. Penicillin based antibiotic prescribed and 2 doses administered before error was noted.

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3.3 REPORTED NON CLINICAL INCIDENTS

Top Reported Incidents by Quarter

0

20

40

60

80

100

120

Q1 05/06 Q2 05/06 Q3 05/06 Q4 05/06 Q1 06/07 Q2 06/07 Q3 06/07 Q4 06/07

Quarter

Num

ber

Violence andAgression

Caught /bumped onequipmentSlip, trip andfalls

Needle stickincidents

Securityincidents

Moving andhandlingincidents

Commentary on statistics During this reporting period there have been a total of 324 non-clinical incident reports received. This is an increase of 6 against the same quarter of the previous year. From the information between the two reporting periods, the most significant increase relates to violence and aggression, which shows an increase of 10 incidents.

Category Q4 05 - 06 Q4 06 - 07 Aggressive Behaviour 35 47 Inappropriate Behaviour of Visitor - 1 Intoxicated - - Non Compliance With Treatment / Care - 4 Objects Thrown 1 2 Offensive Weapon - - Violence to Visitor by Patient 2 1 Threatening Behaviour 5 8 Unco-operative Behaviour 7 8 Unreasonable Force by Security - Verbal Abuse 21 18 Violence to Staff Due to Confusion 3 Violence to Staff Due to Dementia 1 1 Violence by Patient to Patient 1 3 Violence by Patient to Staff 23 17 Violence to Staff Due to Sedation - - Visitor Violence to patient 1 - Total 100 110

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Work in Progress

Ongoing HSE Investigations:

(1) Up date on Health and Safety Executive (HSE) Better Backs Campaign

Following the HSE visit in November/December 2006, which was part of the Better Backs Campaign Inspection of the Trust, the Thrust produced a revised action plan to address several concerns relating to the manual handling issues highlighted by the HSE Inspector. The Trust is in the process of implementing the action within the target date specified.

(2) Up date on Health and Safety Executive (HSE) Inspection of the Diabetic Retinopathy Laser Incident

Following the HSE site Inspection and subsequent Improvement Notice on the Trust relating to the use of Lasers, the Trust produced an action plan to address all the concerns raised within the notice. All the actions have been addressed within the HSE time frame. The Trust received letter from the HSE, acknowledging that the Trust have responded to the HSE’s enforcement action and implemented effective laser use management systems.

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4. FIRE SAFETY

During the past quarter, work has been ongoing to ratify the fire safety SLA between WWL and AWL. At the end of March an agreement, relating to the scope and costs, was made in principle. Over the past 5 years the level of service provision has increased substantially, unfortunately the level of investment has remained the same. This meant that the additional services were provided at the detriment of services to our Trust. The ratification of this agreement will enable the department to undertake fire risk assessments of non-clinical areas, which was previously the responsibility of individual line managers. In addition the audit program which was put on hold is scheduled to re-commence in June 07. Unwanted Fire Signals

The following graph indicates the amount of reported UWFS for the last 4 reporting periods.

Comparison of UWFS for the last 4 reporting periods

68

02 1

86

13

0

6

3 32

0

7

3

02

002468

10

RAEILe

igh

Whelley

Wrighti

ngton

TLC

Site

Am

ount

of U

WFS

1st Qtr 062nd Qtr 063rd Qtr 064th Qtr 06

With the exception of the RAEI all sites have witnessed a reduction of UWFS over the last quarter. The increase at RAEI is attributed to major works program, involving the upgrade of the Phase 2 Fire alarm system.

21


The following table shows the actual grading of UWFS over the reporting

period 06-07, a requirement under FPN11 and the British Standard 5839:

Site Total

Number of Detectors

Total Number of UWFS during the fiscal year

Total Number of Fire during the fiscal year

Detector Years

Grade Remedial action

RAEI 2036 27 75 A Maintain Standard

Leigh 1875 20 94 A Maintain Standard

Whelley 166 4 42 C Reduce number of UWFS by 25%

Wrightington 1170 9 130 A Maintain Standard

TLC 478 1 478 A Maintain Standard

Totals 5725 61 94 A Maintain Standard

Fire Authorities use the grading to assess the Pre-Determined Attendance (PDA) at fire incidents. Organisations who continually fail to meet the minimum requirement (D) will be served notice to improve. If improvements are not made, the fire authority may reduce the level of their PDA, thereby transferring the risk of delayed evacuations to the employer.

22


Below is a Pie chart detailing the total UWFS for the fiscal year as a percentage per site.

UWFS by site as a percentage

43%

33%

7%

15% 2%RAEILeighWhelleyWrightingtonTLC

Fires

There were no reported incidents of fires during the 4th qtr reporting period.

Enforcement notices

External: Non issued.

Internal: None.

The lack of storage facilities on all sites, in particular the main streets and circulation areas at the RAEI, continues to give rise to significant concern. Main causes are excess beds, trolleys, wheelchairs, combustible waste and large amounts of stores. In addition, large quantities of case notes continue to be stored on corridors within admin areas causing obstructions to means of escape routes and exits.

23


5. TRAINING AND DEVELOPMENT SERVICES

Training and Development Services facilitate the Corporate Induction programme, Mandatory taught programmes and the e-mandatory programme. Non-compliance and compliance reports, incorporating all these mandatory training initiatives are forwarded to Divisional General Managers on a quarterly basis.

5.1 Corporate Induction

Induction continues to be held at Wrightington Conference Centre monthly and is multi-disciplinary for all grades.

A review of the Induction has taken place and the findings are presented in a paper being presented at May’s Risk and Environmental Management Group.

5.2 Mandatory Annual Up-Date Programme

The reviewed taught Mandatory program has been delivered as previously on a monthly basis at each of the 3 main sites, RAEI, Wrightington and Leigh. Whilst the move to one single day has proved beneficial in that clinical sessions are delivered on the same day, the programme still requires enormous commitment from all subject experts and leads and also requires staff to be away from the workplace for 1 full day. The provision of mandatory training has been reviewed and the findings are presented in a paper being presented at May’s Risk and Environmental Management Group.

e-Mandatory

The eMandatory programme continues to be actively promoted and is well evaluated with over 1000 staff using this method to receive mandatory updates. Training and Development Services have introduced facilitated elearning sessions. These take place in the eLearning training suite at Wrightington. They are 3-hour tutor supported sessions running both morning and afternoon Tuesdays and Fridays. There are places for a maximum of 8 people per session. Bookings can be made by contacting Syl Hilton.

Mandatory Compliance by Division for period 1 January 2007 to 31 March 2007

Division Non-Compliance %

Compliance % Non-Compliance % Dec 06

Surgical Services 50.60 49.40 60.54 Medical Services 43.58 56.42 51.11 Musculoskeletal Services 46.30 53.67 53.26 Human Resources 5.33 94.67 13.37 Clinical Support 38.84 61.16 48.40 Finance 60.13 39.87 73.26 Estates and Facilities 34.50 65.55 36.30 Small Divisions 52.43 47.57 49.74

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