Board Meeting on: 5 July 2012 Agenda Item: Title: Integrated Clinical and Quality Strategy (ICQS) 2012 -2015 Prepared by: Barry Hutton, Assistant Chief of Operations (Integrated Governance), Halton & St Helens Division Andrea Melbourne, Clinical Governance Manager, Warrington Division Marie Wilson, Head of Governance, Trafford Division Vaughan Reeves, Head of Risk, ALW & Warrington Hitesh Chandarana, Head of Partnership & Engagement, ALW Division All the Clinical Network Leads Michael Smith, Dental Network Divisional Director Dot Keates, Deputy Director of Clinical Leadership & Governance Presented by: Dorian Williams Executive Nurse/Director of Governance Stephen Ward, Medical Director Executive Summary: This paper outlines how the Trust will ensure quality is at the forefront of all the work we undertake. It sets out 4 key quality goals: Clinical effectiveness, Patient Safety; Patient Experience and Quality Governance that we should ensure are at the core of what we do and how we do it. The paper presents an overview of the frameworks we have established (service improvement and redesign; Clinical networks; QIPP) to develop services of high quality and how these frameworks will work together to deliver quality services. The quality objectives that have already been agreed to run the course of the 3 years of the strategy is outlined in Appendix A. Strategic Intentions supported by this paper: Care Quality Commission Outcomes supported by this paper: All Number Title All All CQC outcomes are relevant to this paper Hygiene Code of Practice supported by this paper: Yes Recommendation: To approve the Integrated Clinical and Quality Strategy for 2012 – 2015. Decision:
Transcript
Board Meeting on: 5 July 2012 Agenda Item:
Title:
Integrated Clinical and Quality Strategy (ICQS) 2012 -2015
Prepared by: Barry Hutton, Assistant Chief of Operations (Integrated Governance), Halton & St Helens Division Andrea Melbourne, Clinical Governance Manager, Warrington Division Marie Wilson, Head of Governance, Trafford Division Vaughan Reeves, Head of Risk, ALW & Warrington Hitesh Chandarana, Head of Partnership & Engagement, ALW Division All the Clinical Network Leads Michael Smith, Dental Network Divisional Director Dot Keates, Deputy Director of Clinical Leadership & Governance
Presented by: Dorian Williams Executive Nurse/Director of Governance Stephen Ward, Medical Director
Executive Summary: This paper outlines how the Trust will ensure quality is at the forefront of all the work we undertake. It sets out 4 key quality goals: Clinical effectiveness, Patient Safety; Patient Experience and Quality Governance that we should ensure are at the core of what we do and how we do it. The paper presents an overview of the frameworks we have established (service improvement and redesign; Clinical networks; QIPP) to develop services of high quality and how these frameworks will work together to deliver quality services. The quality objectives that have already been agreed to run the course of the 3 years of the strategy is outlined in Appendix A.
Strategic Intentions supported by this paper:
Care Quality Commission Outcomes supported by this paper:
All Number Title
All All CQC outcomes are relevant to this paper
Hygiene Code of Practice supported by this paper:
Yes
Recommendation:
To approve the Integrated Clinical and Quality Strategy for 2012 – 2015.
Decision:
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Integrated Clinical and Quality Strategy
2012 – 2015
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Statement from Chief Executive and Chairman
This Integrated Clinical and Quality Strategy aims to build on the progress we have already
achieved in our first year as Bridgewater Community Healthcare Trust.
We are committed to delivering safe and effective care which meets or exceeds the
expectations of our patients. We aim to meet this expectation and if we ever fall short
of this commitment, we will be open and honest, and learn from the experience to
continually improve the services we provide.
We have very dedicated staff that are fundamental to achieving this commitment. Therefore
we will also ensure our staff feel supported and valued.
This strategy sets out how we will deliver a quality service to our patients. As the Chief
Executive and Chairman we make a personal commitment to lead the drive for continual
improvement in the quality of service delivery.
Kate Fallon Harry Holden
Chief Executive Chairman
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Contents
Section
Page
1 Introduction
4
2
The need for an Integrated Clinical and Quality Strategy
5
3 Our Mission, Vision and Values
6
4
Our 4 Quality Goals
6
5
Delivery of our Integrated Clinical and Quality Strategy 5.1 Clinical and Quality Objectives 5.2 Clinical Networks and Clinical Network Leaders 5.3 Service Improvement Strategy 5.4 Quality Innovation Productivity and Prevention Strategy 5.5 Quality Impact Assessment Tool
7 7 8 9 9 9
6 Core Principles for Delivering Quality within BCHT
10
7 Our Quality Governance Assurance Framework 7.1 Measuring Quality 7.2 Monitoring the Delivery of this Strategies Action Plan
10 11 12
8 What we aim to Achieve in the First Year (2012/2013)
13
9 Reporting on our Strategy
13
Appendix A Our clinical and quality objectives – action plan 14
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1.0 Introduction Bridgewater Community Healthcare NHS Trust (BCHT) was formed in April 2011. We provide community health services for a population of 1,015,370 people across Greater Manchester, Merseyside and Cheshire. We provide a wide range of community health services from 222 health centres, clinics, hospitals and third sector buildings in the boroughs of Ashton, Leigh & Wigan, Halton, St Helens, Warrington and Trafford. We also provide community dental services in these areas and in Stockport, Bolton, Tameside and Glossop and Western Cheshire. The organisation employs more than 4000 people and manages a total income of £166m. BCHT is registered with the Care Quality Commission (CQC) without conditions. The purpose of the BCHT Integrated Clinical and Quality Strategy (ICQS) is to outline the transformational improvement that will be undertaken over the next 3 years to ensure that all our patients and service users receive excellent care and treatment. In developing this strategy we took into consideration;
The lack of clarity regarding both the future and the alignment of the Strategic Health Authorities (SHA‟s), PCT Clusters and the Clinical Commissioning Groups (CCGs)
The issue that the commissioning intentions and future healthcare priorities of the CCGs are only just becoming apparent
That as yet, it is unclear what role BCHT will have as part of the local Health and Wellbeing Boards, in planning health and social care in line with their Joint Strategic Needs Assessments (JSNA)
We aspire to become one of the first NHS Community Foundation Trusts in 2013 and our aim is that our patients and carers will rate BCHT amongst the best performing community healthcare provider organisations. As an NHS organisation, BCHT is accountable for the services it delivers. This is in accordance with:
the national requirements in terms of policy through the Department of Health (DoH)
regulation through the CQC and Monitor
clinically relevant outcomes as evidenced in accordance with the National Institute for Health and Clinical Excellence (NICE) and the NHS Outcomes Framework.
In order to benefit from the lessons learned elsewhere we will review recommendations from reports and inquiries into other NHS trusts. For example:
Care and Compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people
Robert Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust
We will ensure that we meet the needs of our local population and our key stakeholders which include our commissioners, LINks, Overview and Scrutiny Committee‟s, staff and Health and Wellbeing Boards. In order to achieve this we will work closely and collaboratively with other healthcare providers, such as acute hospitals, GPs, mental health trusts and the ambulance service.
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Fundamental to achieving all of the above is the dedication and care that our staff deliver on a daily basis. In order to ensure the on-going commitment of our staff we will:
ensure our staff feel valued and supported
provide effective leadership
provide opportunities for continuing professional development
provide an appropriate rewards and incentives package
provide a range of health and wellbeing support initiatives. This strategy will guarantee that we engage all our services and staff in developing care which is patient centred, safe and effective whilst also taking into consideration efficiency, equity and timeliness.
2.0 The need for an Integrated Clinical and Quality Strategy There are a number of external drivers which have influenced the development of this strategy:
All NHS Trusts are required to meet „Essential Standards of Quality and Safety‟, Care Quality Commission.
Health and Social Care Bill 2011. The new Health and Social Care Bill highlights:
Greater voice for patients (“no decision about me without me”) Improving quality of care – quality enshrined in law, clinical results,
„currency of the NHS‟, clinicians playing a greater role in setting the delivery of clinical services.
New focus for Public Health – improved health and wellbeing.
Quality, Innovation, Productivity and Prevention (QIPP). QIPP is a large scale transformational programme for the NHS, involving all NHS staff, clinicians, patients and the voluntary sector working across organisational boundaries. It will improve the quality of care the NHS delivers whilst making up to £20billion of efficiency savings by 2014-15, which will be reinvested in frontline care.
NHS Operating Framework 2012/13. The Operating Framework for the NHS in England 2012 highlights:
Improving services and patient experience. Areas requiring particular attention – dementia and care of older people,
carers and Health Visitors & Family Nurse Partnerships.
Monitor‟s Quality Governance Framework (July 2010) for NHS Foundation Trusts. The framework assesses the combination of structures and processes in place, both at and below board level, which enable a trust board to assure the quality of care it provides.
NHS Outcomes Framework 2012/13. The NHS outcomes framework sets out the outcomes and corresponding indicators that will be used to hold the NHS Commissioning Board to account for the outcomes it delivers through commissioning health services from 2012/13. The framework sets the direction of travel on the journey towards improving outcomes, and offers an opportunity for the NHS to begin to understand what an NHS focused on outcomes means for individuals, organisations and health economies.
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Department of Health White Paper – Equity and Excellence: Liberating the NHS. This White Paper sets out the Government's long-term vision for the future of the NHS. The vision builds on the core values and principles of the NHS - a comprehensive service, available to all, free at the point of use, based on need, not ability to pay. It sets out how we will:
put patients at the heart of everything the we do; focus on continuously improving those things that really matter to our
patients - the outcome of their healthcare; and empower and liberate clinicians to innovate, with the freedom to focus on
improving healthcare service.
NHS Equality Delivery System (EDS). The EDS has been designed as an optional tool to support NHS commissioners and providers to deliver better outcomes for patients and communities and better working environments for staff, which are personal, fair and diverse. The EDS is all about making positive differences to healthy living and working lives.
Commissioning for Quality and Innovation (CQUIN) Framework. The framework
enables commissioners to reward excellence by linking a proportion of providers‟ income to the achievement of local quality improvement goals.
3.0 Our Mission, Vision and Values Our Mission: To improve local health and promote wellbeing in the communities we serve. Our Vision: By working with local people and partners, we will promote good health and be a leading provider of excellent community healthcare services in the North West.
Our Values:
Patient Centred - Patient care is our priority
Encourage Innovation - We encourage and embrace new ideas to deliver improvements in patient care
Open and Honest - We communicate clearly to develop relationships based on mutual trust and respect
Professional - We provide a quality service for patients by investing in our staff and recognise and value their contribution
Locally led - We will continually develop our knowledge of the communities we serve so that we can be responsive to local need
Efficient- We will use our resources wisely to ensure quality patient care and value for money.
4.0 Our 4 Quality Goals The Next Stage Review, High Quality Care for All, defined quality in the NHS as consisting of the following key components: Patient Safety, Patient Experience, and Clinical Effectiveness .
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We believe our patients have a right to expect services which are not only free at the point of delivery but are safe, effective, meet their individual needs and take their views into account. As such, we have adopted the 3 key elements in the review as our „Goals‟ and added a fourth goal covering Quality Governance. We will ensure that BCHT delivers a range of initiatives and projects to maintain high quality services.
Goal 1: Patient Experience BCHT aims to ensure that our patients, their relatives and carers will have a memorable experience for the right reasons which meets or exceeds their expectations and needs.
Goal 2: Clinical Effectiveness BCHT will become a UK leader in healthcare delivering clinically effective treatment which is delivered by well trained, highly skilled practitioners. We will also, wherever possible help to improve the health and wellbeing of our local population by providing information and support.
Goal 3: Patient Safety BCHT will strive to ensure we provide a safe service by ensuring that there is zero tolerance to harm caused by our clinical or care practice; we will ensure that we provide a safe environment for our patients and staff alike.
Goal 4: Quality Governance BCHT will ensure effective systems, processes and controls in order to deliver, monitor, measure and assure the care that we provide. We will ensure that meaningful governance processes, continually promote improvements.
5.0 Delivering our Integrated Clinical and Quality Strategy 5.1 Clinical and Quality Objectives
The delivery of our strategy will be through the proactive management of a series of projects. The projects are designed to contribute to our aim of delivering safe and effective care which meets or exceeds the expectations of our patients. A summary of these projects under each goal is outlined below. Further detail relating to delivery of each of the projects can be found in the action plan at Appendix A. . Goal 1: Patient Experience
Develop a Patient Charter
Undertake regular patient experience surveys
Conduct staff surveys to ensure staff are listened to and engaged
Implement lessons learnt
Implement „Important Choice‟ agenda
Implement „A call to action‟ (Health Visitor Implementation plan)
Develop alternative methods to engage patients
Develop Engagement strategy for Members and Governors
Goal 2: Clinical Effectiveness
Clinical Network Forum to drive forward continuous improvement
Development of care pathways for conditions managed through Long Term
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Care, Urgent Care and Specialist Services
Greater integration and collaboration across pathways
Implementation of Telehealth and Telecare programmes
Reduce variation in Offender Health provision
Improve access and support to children aged 0-5
Development of clinical effectiveness and performance indicators Goal 3: Patient Safety
Increase Patient Safety Incident reporting and reduce Actual Harm levels from incidents
Reduce prevalence of pressure ulcers; catheter acquired infections; and falls in inpatient/intermediate care facilities
Maintain robust infection prevention and control arrangements
Ensure effective risk management processes
Establish and maintain safe and clean community premises Goal 4: Quality Governance
Implement a revised governance structure
Monitoring of Integrated Clinical and Quality Strategy
Ensure compliance with Monitor Governance Framework
Learn lessons from national reports and enquiries
Implement effective service line reporting and monitoring framework
Undertake Environmental Walk-rounds in clinics
Utilise Quality Impact Assessment Tool
Maintain CQC Registration without conditions
5.2 Clinical Networks and Clinical Network Leaders
Strong and effective clinical engagement is essential if the organisation is to live by its value of encouraging innovation and embracing new ideas to deliver improvements in patient care. BCHT has established the following clinical networks that will work across all divisions to enable this to happen.
Clinical Networks
Urgent Care
Child Health
Health and Wellbeing (including Dental Network)
Offender Health
Specialist Service
Long Term Conditions
Each of these networks will be led by an experienced clinical leader. These networks and the clinical network leaders, will be fundamental in engaging frontline clinicians in meaningful and systematic clinical service redesign. The key overall objectives of the clinical networks are:
Clinical leadership
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Service improvement and redesign
Pathway redesign
Efficiency across services (Cost Improvement Plans)
Effective service line management
The clinical network leads will be professionally accountable to the Executive Nurse/Director of Governance and operational accountability for delivering the service improvements to the Director of Operations. Our divisional and clinical leadership model across the organisation is shown below.
A Divisional and Clinical Leadership Matrix
De
liv
ery
an
d A
cc
ou
nta
bilit
y
Clin
ica
l se
rvic
es
Fin
an
ce
Pe
rfo
rma
nce
Qu
alit
y
Re
form
Clin
ica
l S
tand
ard
s
DENTAL TRFRD ALW HStH WGTN
URGENT CARE
CHILD HEALTH
HEALTH & WELLBEING
OFFENDER HEALTH
SPECIALIST SERVICES
LONG TERM CONDITIONS
Delivery and Advice
Service improvement
Pathway redesign
Specialist clinical advice
Urgent care integration advice
Geographical service integration advice
Efficiency across services (CIP)
Service line management
5.3 Service Improvement Strategy
BCHT has developed a Service Improvement Strategy which sets out how the organisation will ensure effective service improvement activities that impact positively on the care our patients receive.
5.4 Quality Innovation Productivity and Prevention Strategy
BCHT has developed a 5 year Quality, Innovation, Productivity and Prevention (QIPP) strategy to promote a culture within the organisation that believes keeping services safe and improving patient care can co-exist within increasing efficiency, productivity and with reducing costs.
Our QIPP strategy has clear objectives for each of these 4 elements (quality; innovation; productivity and prevention) that dovetail with other key programmes of change, identified in our Integrated Business Plan.
5.5 Quality Impact Assessment Tool
BCHT have developed a Quality Impact Assessment tool (QIAT) that will ensure that any service improvements, redesigns or QIPP initiatives, (especially those that arise from Cost Improvement Plans (CIP)) have been assessed to safeguard clinical
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quality. Each QIAT will be signed off by the Executive Nurse/Director of Governance and the Medical Director before being implemented.
6.0 Core Principles for Delivering Quality within BCHT Our core principles for the delivery of our Integrated Clinical and Quality strategy are:
Adherence to standards of clinical excellence to maintain and improve the health and
well-being of the local community
Care pathways will be evidence based and referenced
Services will provide value for money, without compromising the quality of care
delivered. All cost improvement plans will be subject to a quality impact assessment to
safeguard clinical quality.
Public health intelligence will underpin our understanding of, and planning for local
service delivery, addressing the health inequalities which exist across the Bridgewater
divisions.
Patient, service user and carer involvement in service development is key to
understanding experience and how this can be improved
Prevention and self-management will be an integral part of service review and
development
Integration of services, where there is potential to improve quality and experience, and
reduce cost will be promoted
Patients, service users and carers will be encouraged to participate in decision making
about their care, promoting the benefit of a shared understanding of managing clinical
risk in decision making.
In order to achieve the above, BCHT will:
Foster clinical leadership through strong clinical engagement
Ensure that clinicians are at the centre of decision making around service redesign
Ensure that clinical staff develop the skills and have the resource to develop and deliver
robust service improvement plans
Actively involve patients/service users, the public and the workforce in shaping both the
organisation and clinical service delivery.
Create a culture of learning and development, encouraging the application of new
knowledge and skills.
Identify gaps in data for quality outcomes
7.0 Our Quality Governance Assurance Framework As stated in Monitor‟s Quality Governance Framework document (July 2010) quality governance is the combination of structures and processes, at and below board level, to lead on trust-wide quality performance. BCHT‟s committee structure and clearly identified Board member responsibilities ensures that there are quality governance arrangements in place to facilitate the effective monitoring of all aspects of the quality agenda. For example;
Compliance with Monitor‟s regulatory requirements
Compliance with Care Quality Commissions Registration Requirements
Compliance with Health and Social Care Act 2008 (Hygiene Code)
Compliance with NHSLA Risk Management Standards 2012-13
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To check the robustness of our current structures and processes a full assessment of compliance with the Monitor‟s Quality Governance Framework requirements has been undertaken and an action plan developed to address any identified shortfalls in compliance. 7.1 Measuring Quality
The diagram below shows the Bridgewater Integrated Quality Performance Framework.
Bridgewater currently collates data relating to three of the above four domains above:
Governance and clinical safety including Serious Untoward Incidents, Healthcare Acquired Infections etc.
Human Resources and Organisational Development, including sickness, training, professional registration, training etc.
Finance including Cost Improvement Plans, activity, waiting lists, contract performance and performance against specific national targets and thresholds.
BCHT is actively developing, for implementation in 2012/13, business intelligence software that all heads of service will have access to, that will bring together the above data into one performance monitoring tool. This tool will enable effective service line management and reporting from clinical teams to divisional management teams and ultimately to BCHT Board. The analysis and reporting of this data will enable services and divisions to monitor quality from the best indicators currently available. The clinical effectiveness and clinical performance domain (shaded in diagram above) and benchmarking data in community healthcare services is nationally not well advanced. The Director of Clinical Performance is working with the Foundation Trust Network and a number of aspirant Community Foundation Trusts on developing a set of quality indicators that are appropriate for Community Healthcare Providers. It is anticipated that this work will assist in the influence of the Monitor Compliance Framework for Community Foundation Trusts. BCHT will implement the measurement and monitoring of quality indicators for Community Foundation Trusts once established. There is a general acknowledgement that these discussions are still at an early stage and that a number of principles should apply: -
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Indicators and thresholds should be achievable but stretching
They should reflect community services activity rather than be acute trust metrics transposed to community services
There should be measures of data quality & data completeness
That metrics should evidence progress “towards good governance”
That a trajectory towards full compliance is developed with achievement by April 2014.
As part of this project Bridgewater‟s Clinical Network Leads will work with our commissioners to identify service/Network specific clinical effectiveness indicators. This approach will support comparison between the same services provided in our different divisions. Early discussions with Clinical Commissioning Group‟s (Halton & St Helens and Warrington) and NHS Merseyside suggest that they would support this approach as it aids transparency, is clinically significant and engaging and it also reduces the burden of both data reporting and performance management. In addition a significant focus for the organisation in terms of measurement will be relating to harm. We will be using the Department of Health local improvement tool “The NHS Safety Thermometer” to help us understand the frequency of four specific harms i.e. falls, pressure ulcers, catheter associated urinary tract infection and venous thrombo-embolism.
7.2 Monitoring the Delivery of this Strategies Action Plan
Our internal committee structure is outlined below. Each of these committees has a role to play in monitoring the objectives we have identified in Appendix A; as well as the overall review and amendment to this strategy.
The Trust Board has overall responsibility for the scrutiny of the quality and clinical governance (including patient experience) agenda and for meeting all the statutory requirements. The board leads and directs quality and its governance by ensuring that the board agendas include focus on patient safety and quality.
The Audit Committee – is a non-executive scrutiny group acting as the key assurance group for the Board reviewing both financial and quality assurance. The Chair of the Audit Committee is also a member of the Quality and Safety Committee and is responsible for reporting key activities from the Audit Committee to the Quality and Safety Committee.
The Performance Committee – is a sub-committee of the Board supporting a top level interface to triangulate clinical, workforce, financial performance and to be aware of the levels of the associated risks and reporting them to the board.
Bridgewater Community Healthcare NHS Trust Board
Performance Committee
Audit Committee
Quality and Safety Committee
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The Quality and Safety Committee - a sub-committee of the board which monitors and assures on all aspects of integrated governance including patient safety, quality and reports assurance to the Board.
The Divisional Management Teams – review, implement and report into the board and sub-committees to provide assurance on the delivery of safe and high quality care of the services they provide.
8.0 What we aim to Achieve in the First Year (2012/2013) We aim to achieve the following key objectives within the first year of this strategy:
A Patient charter will have been developed
Engagement plans will be in place for members and governors; as well a programme of patient and staff surveys
Effective system of identifying and sharing lessons learnt will be in place
Clinical networks will be meeting regularly, each with a clearly defined work-plan to improve clinical effectiveness
We will have implemented a strategy for Telehealth and Telecare across BCHT
Established the arrangements to review provision of Offender Healthcare
Defined the baseline target to increase patient safety incident reporting
Developed plans to effectively contribute to reduction of pressure ulcers; catheter acquired infections; and falls in inpatient and intermediate settings
Maintained adherence to Hygiene Code
Implemented our Community Premises Inspection Team programme
Revised Governance Structure will be in place
We will have reported via the Quality and Safety Committee to our Board on the effectiveness of the strategy and its objectives
Taken on board any actions which arise from the Monitor Quality Governance Framework
Established clear accountability for the review and reporting within BCHT on any national reports and inquiries
Implemented a service line reporting and management business performance tool
Walk rounds will in place, led by a member of our Executive Team
Quality Impact Assessments will have been undertaken for any Cost Improvement Plans
We will have maintained our registrations with CQC without conditions
9.0 Reporting on our Strategy Our Quality and Safety Committee will receive a bi-annual report on the progress we have made with the implementation of our „strategy‟. New objectives identified will be included in an annual revision of the action plan in Appendix A. We will ensure that our Annual Quality Account outlines our achievements at the end of each year.
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Appendix A: Our quality objectives – action plan
Go
al 1
– P
atient
Exp
erie
nce
Objective How this will be achieved Target / Threshold
Monitoring Frequency
Monitoring method
Target Date
1
Develop a Bridgewater Patient Charter
Service Experience Group will develop Charter with involvement from members
Published Charter
Annual
Service Experience Group
March 2013
2
Ascertain patient‟s views regarding the quality of our services on a regular basis ensuring that patients
Are treated with respect and dignity Are provided with appropriate information or advice Have confidence and trust in health
professional(s) Receive the care that mattered to me
Development of a rolling programme of patient surveys
90% 90% 90% 90%
Quarterly
Service Experience Group Quality and Safety Committee
March 2013
3
Conduct staff Surveys within BCHT on a regular basis, in addition to the National Staff Survey, o ensure staff are: -
Listened to and involved in shaping our decisions and strategic approaches
Motivated to provide the best patient experience
Regular Staff Experience Surveys
80% 80%
Quarterly
Service Experience Group/Quality and Safety Committee
July 2012
4
Ensure lessons learnt from complaints/PALS are identified, acted upon and shared across the organisation
Patient Services Department to identify and disseminate.
At least one per quarter
Quarterly
Service Experience Group Quality and Safety Committee
July 2012
5
The Trust will continue the implementation of the „Important Choice‟ agenda (End of Life Care Pathway) supporting patients to be cared for in the place of their choice.
Actively participate in ICP review jointly with local acute trust and local hospice.
100%
6 monthly
Clinical Audit
April 2012
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6
The Trust will implement the new model for health visiting -„A Call to Action Health Visitor Implementation Plan‟ All Divisions will develop alternative methods of seeking service feedback including for example:
SMS texting
Family Echo
Care Cards
Steering group established to monitor delivery of „Call to Action‟ action plan Each Division to agree alternative methods Implement Service Feedback
Agreed staffing trajectories Methods agreed
Quarterly Biannually
HV Executive Group in conjunction with Service Experience Group Service Experience Group
End March 2015 End March 2014
7
The Trust will engage Members and Governors in ensuring the Board receives timely patient experience feedback via:
Council of Governors Regular Involvement Activities Annual Member Survey
Ascertain Members and Governors views regarding the quality of our services and areas for quality improvement
Engagement plan developed and agreed Development of member survey
To be defined
Quarterly Annually
Board
April 2013 April 2013
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Go
al 2
– C
linic
al E
ffe
ctive
ne
ss
Objective How this will be achieved Target / Threshold
Monitoring Frequency
Monitoring method
Target Date
1
Clinical Network forum to drive forward continuous improvement of services for patients, and their carers/families through clinical engagement
Regular Clinical Forum meetings
Clinical Networks developed through staff engagement
By engaging with front line staff, patients, key agencies, local networks and stake holder groups to ensure that healthcare deliver and the wider determinants of the health and wellbeing are reflected local strategies, care pathways and implementation plans.
Action plans developed and approved for each Clinical Network
Performance measured against achievement of action plans
100% of services
Quarterly
Clinical network review group Quality and Safety Committee
Sept. 2012 Sept. 2012 Sept. 2012 – Sept 2013 April 2013 March 2014
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2
To focus on the development of care pathways (map of medicine) specifically for end of life, dementia, cancer, and early diagnosis, and other long term conditions managed through Urgent Care and Specialist Services networks.
Identifying and reducing inappropriate variation in clinical practice and in the provision of care across all clinical pathways. By benchmarking the care pathways against current, valid and reliable evidence underpinned with local population health intelligence. Developing and supporting a workforce that is skilled and competent to deliver care within an integrated care pathway. Where appropriate promoting greater integration and a whole system approach to the provision of clinical care, including partnership with primary, secondary and tertiary care.
To identify devise and implement systems and processes necessary to deliver and monitor the clinical effectiveness of the clinical pathways.
In line with divisional JNA‟s developed in partnership with the wider health and social care economy, patients, carers and clinicians.
Quarterly
Clinical network review group Quality and Safety committee
Sept 2012. – Sept 2013
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Ensuring that a system is in place to review, prioritise, implement and monitor the provision of care pathway. Providing specialist advice through Clinical Networks to provide a mechanism for patient, carers and clinicians to be involved in specific planning and strategic thinking.
3
To maximise the potential for an integrated approach to providing effective and efficient care patient care across the health and social care economy.
Identifying and reducing duplication of care and establishing efficient and effective care pathways that are patient centred. Supporting self-care and promoting health and wellbeing for all. Benchmarking care provision against current, valid and reliable evidence underpinned with local population health intelligence and local health and social care systems. By working closely with
In line with divisional JNA‟s developed in partnership with the wider health and social care economy, patients, carers and clinicians.
Quarterly
Quality and Safety committee
End March 2015
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partners and the third sector to ensure that a whole system approach is in place to review, prioritise, implement and monitor the provision of care. . Providing specialist advice through Clinical Networks to offer a mechanism for patients, carers and clinicians to be involved in care specific planning and strategic thinking. Ensuring patients and carers have access to health and wellbeing services by ensuring that all patient facing staff have the competences, confidence and resources to refer patients and carers to health and wellbeing services.
4
BCHT will put in place a communication technology (telehealth/telecare) and resource programme to support self-care and increase health literacy within its patient and carer population. Whilst delivering efficiency gains by supporting patients to manage their care and live more independently.
Implementing a Telehealth/telecare programme that supports the management of care of BWCH patients. Ensuring that patients and
To increase usage in each division by 50%
Quarterly
Group already established unsure of name
End March 2013
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carers have access to the information and advice they need when and where they need it in order to support and maintain their health and wellbeing and independence. By supporting patients and carers to manage ill health and give them the confidence to participate fully in shared decision making.
5
Review BCHT offender health provision to reduce inappropriate variation and maximise quality of services provided
Implement structures and processes necessary to deliver and monitor the clinical effectiveness of the offender health care. Benchmarking current offender health provision in the 3 prison sites in relation to service efficiency, cost effectiveness, performance and quality.
Identify and report on KPIs and Outcome Measures Service reviews for all 3 prison sites in line with KPIs
Quarterly
Divisional Management Teams
End March 2013 End March 2014
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Establish a system for consistency of early detection, diagnosis and management of physical and mental health issues (eg, learning disability, hearing problems or dementia), throughout all offender healthcare services Ensure best practice within clinical teams and health and wellbeing services are shared across Offender Healthcare
Benchmark current
screening tools and pathways against quality
standards Membership of Offender Health Forum and other existing forums
End March 2014 End March 2015
6
Child Health: Early Years To improve life chances for children aged 0-5 by improving the level of access and support to families with children from 0-5 in line with the DOH Health Child Programme (2009).
The Health Visitor Implementation plan is being planned and delivered across divisions, building the workforce and planning to implement changes which will improve access to universal services, support to families with short term additional needs, and support to families with
100% of Services
Quarterly
HV Executive Group
End March 2014
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more complex needs. Partnership working between Health Professionals, Children‟s Centres, Education and Social Care will be key to successful outcomes. The Child Health Network will facilitate the development of networks to share learning and to support the development of integrated working practices to support ease of access and delivery of the services required. Utilising learning from Family Nurse Partnership initiative.
7
Development of a range of clinical effectiveness and performance indicators
Development of indicator set in collaboration with other aspirant community providers and foundation trust network Indicators integrated into performance management framework Heads of Service and Divisional Directors report against agreed indicators
Indicators agreed
Quarterly
Performance committee Divisional Management Teams
End March 2014
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Go
al 3
– P
atient
Safe
ty
Objective How this will be achieved Target / Threshold
Monitoring Frequency
Monitoring method
Target Date
1
Increase Patient Safety Incident reporting and reducing Actual Harm levels
Release encouraging
communication and feedback to increase incident reporting
Utilise weekly reviews to monitor and correct Actual Harm levels and Patient Safety Incident identifiers, and feedback to staff to increase learning
Embed the Investigation Procedure to identify root causes and implement positive service change to avoid recurrence and reduce Actual Harm
To be established from statistics from NPSA
6 monthly
6 monthly
NPSA patient safety incident statistics
Based on the NPSA patient safety incidents statistics, achieve recognition in the top quartile for community trusts for the number of incidents reported with the lowest quartile for incident severity (patient harm)
June 2013
Page 25 of 28
2
Reduce or contribute to the reduction of: - Community developed or deteriorating pressure ulcers Residential home and acute trust developed or
deteriorating pressure ulcers Catheter acquired infections in the community Falls in inpatient and intermediate care facilities
The Trust will continue the implementation of the nationally recognised „Your Skin Matters‟ All divisions will implement the NHS Safety Thermometer requiring collection of data in relation to pressure ulcers, falls and urinary tract infections for patients with a catheter Further implement the Patient Safety Express initiative and roll out concept across Divisions not yet engaged Implement the „Staying Safe Initiative‟ reducing the incidents of falls within the inpatient setting
To be established
Quarterly
NHS
Safety Thermometer data
Incident reporting (incl. External agency statistics) and SUI data
Quality and Safety Committee incident report
Monitor pressure ulcer questionnaires from incident reports
April 2013
3
Maintain adherence to the requirements of Hygiene Code of Practice. Establish a culture of „no avoidable infections‟
Training programme Organisational Audit arrangements Implementation of effective infection control practices
To be established Thresholds set for all divisions (except Dental) for
Quarterly
Quality
and Safety Committee Infection Control report
Infection Control Assurance
April 2013 April 2013
Page 26 of 28
MRSA and CDI
Framework Infection
Control Audit programme
Incident reporting
4
Implement a comprehensive, consistent, and patient centred approach to risk management across the Trust
Develop and implement a trust-wide range of policies, procedures, and clinical guidelines that can be enacted consistently across all Divisions
Compliance with NHSLA Risk Management Standards at Levels 1 and 2
Annually
NHSLA
Self assessment tools
Formal external NHSLA assessment
April 2014
5
Establish and maintain safe and clean community premises which are fit for purpose
Implement the Community Premises Inspection Team Programme (CPIT) across all divisions
To undertake a consistently applied CPIT, once per annum per property, with action plans that include time bound outcomes
Quarterly
Inspection
results and reports to the Quality and Safety Committee and Board
April 2013
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Go
al 4
- G
overn
an
ce
Objective How this will be achieved Target / Threshold
Monitoring Frequency
Monitoring method
Target Date
1
Reconfigure a governance structure that reflects the needs of the new organisation
Undertake review of governance requirements across Bridgewater New structure implemented
In place by Qtr 2 12/13
Annually
Report to Quality and Safety Committee
End Qtr 2, 12/13
2
Ensure effective monitoring of Integrated Quality Strategy to ensure key aims and objectives are realised
Assurance and monitoring framework established Reports to Quality and Safety Committee quarterly
IQS at July Board Quarterly reports thereafter
Quarterly
Report to Quality and Safety Committee
March 2013
3
Ensure compliance with the Monitor Quality Governance Framework (July 2010)
Complete assessment of compliance with Monitor Quality Governance Develop action to address any identified gaps
Full compliance by March 2013
Monthly
Report to Board
End Qtr 4, 12/13
4
Ensure BCHT learns the lessons from all relevant National reports and enquiries
Identified leads to review assigned reports in order to identify any organisational gaps or developments
All relevant reports reviewed and changes made as necessary
Quarterly
Report to Quality and Safety Committee
Ongoing to March 2015
5
Implement an integrated business intelligence reporting
Business Intelligence
SLR/SLM
Monthly
Performance
End
Page 28 of 28
framework (SLR/SLM) across all service lines to ensure heads of service, divisional directors can monitor and report on their performance from service line to board
software rolled out being utilised
reports from Divisions to Performance Committee
Qtr 2, 12/13
6
Implement a programme of „walk-rounds‟ to monitor the environmental standards within clinics, led by Executive and Non-Executive Directors
Clear programme/framework established; briefing of Executive/Non-Executive Directors
Walk rounds in place
Biannually
Report to Quality and Safety Committee
End Qtr 2, 12/13
7
Ensure Bridgewater Quality Impact Assessment Tool (QIAT) is completed for all Cost Improvement Plans (CIPS) and service redesigns.
Define the triggers that will initiate the completion of the Bridgewater Quality Impact Assessment Tool (QIAT) for all Cost Improvement Plans and service redesigns Develop monitoring process to ensure all CIPS and service redesigns have completed a QIAT
QIAT‟s completed for all CIPS and service redesigns which are approved by Executive Medical Director and Executive Nurse/Director of Governance
Quarterly
Report to Performance Committee
End Qtr 2, 12/13
8
Maintain CQC Registration without conditions for all regulated activities.
