Systems & Processes Regular assurance to Instances of Nursing and Senior Nurse Ongoing Systems will be in place to Board Reports mixing will be Patient Services Practice assure the Board of the Board. reported as per Director Development compliance with MSSA Monthly returns to DoH policy. principles. A system of monitoring justified all occurrences of instances of Instances of mixing will be EMSA Policy available to mixing, whether sleeping escalated and investigated staff and Patients, clinically justified or not accommodation contains clear reporting breaches will be arrangements. reported at Board level and via Unify to DoH Where there are rare Reporting will Nursing and Senior Nurse Ongoing Systems will be in place to Board Reports take place Patient Services Practice assure the Board of occurrences for through as per Director Development compliance with EMSA Exception reports to SHA reasons, a policy principles. and RCA where required process exists to (none in 2012-13, investigate reason, take Root cause Instances of mixing will be 2014-15 or 2015-16) prompt action and take analysis (RCA) escalated and investigated remedial actions as will be undertaken for any instances required to prevent of mixing future occurrence Relevant Trust Trust policies will Nursing and Senior Nurse Ongoing Trust policies will support Same Sex make Patient Services Practice the delivery of SSA. Accommodation Policy policies refer to expectations clear Director Development requirement to EMSA in relation to Privacy and Dignity Policy and privacy and dignity EMSA and privacy and Transfer of Patients Policy dignity Visitors Policy
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
A5vi_Eliinating_Mixed_Sex_Accommodation.docx